Healthcare Provider Details

I. General information

NPI: 1780734574
Provider Name (Legal Business Name): JACK PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 E SHIELDS AVE
FRESNO CA
93726-7029
US

IV. Provider business mailing address

970 MAKENNA ST
LEMOORE CA
93245-4502
US

V. Phone/Fax

Practice location:
  • Phone: 559-229-9040
  • Fax: 559-229-9060
Mailing address:
  • Phone: 559-924-0663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: