Provider Demographics
NPI:1619207735
Name:PORTER, JANINE
Entity Type:Individual
Prefix:
First Name:JANINE
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1393 ALDER ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7828
Mailing Address - Country:US
Mailing Address - Phone:805-540-4969
Mailing Address - Fax:
Practice Address - Street 1:1393 ALDER ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7828
Practice Address - Country:US
Practice Address - Phone:805-540-4969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-12
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CALMFT107978106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program