Provider Demographics
NPI:1508040338
Name:PORTER, JEAN TAYLOR (LCSW)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:TAYLOR
Last Name:PORTER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 MINDEN LN
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-7429
Mailing Address - Country:US
Mailing Address - Phone:214-597-9298
Mailing Address - Fax:
Practice Address - Street 1:1021 MINDEN LN
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-7429
Practice Address - Country:US
Practice Address - Phone:214-597-9298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07012171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXSW00S41G2Medicaid