Provider Demographics
NPI:1649513979
Name:PORTER, JENNIFER ANN (DNP, CNM)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:ANN
Last Name:PORTER
Suffix:
Gender:F
Credentials:DNP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 30TH AVE W
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308-3426
Mailing Address - Country:US
Mailing Address - Phone:320-763-5123
Mailing Address - Fax:320-763-7883
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3426
Practice Address - Country:US
Practice Address - Phone:320-763-2540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-04
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1649513979OtherNPI
MNR-145018-3OtherRN LICENSE
MN1649513979Medicaid
MN1649513979Medicaid