Provider Demographics
NPI:1649519091
Name:PORTER, JEANINE GLADYS
Entity type:Individual
Prefix:MS
First Name:JEANINE
Middle Name:GLADYS
Last Name:PORTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-3475
Mailing Address - Country:US
Mailing Address - Phone:320-231-9763
Mailing Address - Fax:320-235-0334
Practice Address - Street 1:328 3RD ST SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-3475
Practice Address - Country:US
Practice Address - Phone:320-231-9763
Practice Address - Fax:320-235-0334
Is Sole Proprietor?:No
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN301951101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)