Provider Demographics
NPI:1255510681
Name:PORTER, JEFF GLEN (PT)
Entity type:Individual
Prefix:MR
First Name:JEFF
Middle Name:GLEN
Last Name:PORTER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 AZALEA RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-1970
Mailing Address - Country:US
Mailing Address - Phone:251-476-0192
Mailing Address - Fax:251-479-1417
Practice Address - Street 1:273 AZALEA RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-1970
Practice Address - Country:US
Practice Address - Phone:251-476-0192
Practice Address - Fax:251-479-1417
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH4382225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist