Provider Demographics
NPI:1689121386
Name:PORACKY, JESSICA L (RN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:PORACKY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6840 GLENDALE AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-4526
Mailing Address - Country:US
Mailing Address - Phone:330-921-1174
Mailing Address - Fax:
Practice Address - Street 1:6840 GLENDALE AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-4526
Practice Address - Country:US
Practice Address - Phone:330-921-1174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-09
Last Update Date:2016-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.325835163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse