Provider Demographics
NPI:1154755171
Name:PORTER, JENNIFER MOORE (SLP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MOORE
Last Name:PORTER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ALISON
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4992 BRISTOL INDUSTRIAL WAY
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30518-1742
Mailing Address - Country:US
Mailing Address - Phone:770-904-6419
Mailing Address - Fax:770-904-6418
Practice Address - Street 1:4992 BRISTOL INDUSTRIAL WAY
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30518-1742
Practice Address - Country:US
Practice Address - Phone:770-904-6419
Practice Address - Fax:770-904-6418
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-27
Last Update Date:2013-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP007334235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist