Provider Demographics
NPI:1609948868
Name:PORTER, JEANELLE H (PT)
Entity Type:Individual
Prefix:
First Name:JEANELLE
Middle Name:H
Last Name:PORTER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N EAGLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-1805
Mailing Address - Country:US
Mailing Address - Phone:859-258-5073
Mailing Address - Fax:859-258-5074
Practice Address - Street 1:100 N EAGLE CREEK DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-1805
Practice Address - Country:US
Practice Address - Phone:859-258-5073
Practice Address - Fax:859-258-5074
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT-0019072251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4000501OtherMEDICARE LAB GROUP
KY650025330OtherRR MEDICARE PIN
KY37903705OtherMEDICAID LAB GROUP
KYCB5773OtherRR MEDICARE GROUP
KYCB5773OtherRR MEDICARE GROUP
KY650025330OtherRR MEDICARE PIN