Provider Demographics
NPI:1922296656
Name:PORTER, JENNIFER (NP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:490A W ZIA RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-6996
Mailing Address - Country:US
Mailing Address - Phone:505-913-8900
Mailing Address - Fax:505-913-8923
Practice Address - Street 1:490A W ZIA RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-6996
Practice Address - Country:US
Practice Address - Phone:505-913-8900
Practice Address - Fax:505-913-8923
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-01564363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200880420Medicaid
IN237180BMedicare PIN
NMNM303038Medicare PIN
IN200880420Medicaid