Provider Demographics
NPI:1669138608
Name:PORTER, JESSICA MARIE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:MARIE
Last Name:PORTER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28760 PERDIDO BEACH BLVD UNIT 604SE
Mailing Address - Street 2:
Mailing Address - City:ORANGE BEACH
Mailing Address - State:AL
Mailing Address - Zip Code:36561-3369
Mailing Address - Country:US
Mailing Address - Phone:251-987-0486
Mailing Address - Fax:
Practice Address - Street 1:25761 PERDIDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE BEACH
Practice Address - State:AL
Practice Address - Zip Code:36561-6107
Practice Address - Country:US
Practice Address - Phone:251-974-1590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-15
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS57365183500000X
NC22878183500000X
AL17018183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist