Healthcare Provider Details

I. General information

NPI: 1467727081
Provider Name (Legal Business Name): JACOB STEPHEN PORTER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2012
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7117 BROCKTON AVE
RIVERSIDE CA
92506-2658
US

IV. Provider business mailing address

7117 BROCKTON AVE
RIVERSIDE CA
92506-2658
US

V. Phone/Fax

Practice location:
  • Phone: 951-782-3685
  • Fax: 951-784-3256
Mailing address:
  • Phone: 951-782-3685
  • Fax: 951-784-3256

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PP0204X
TaxonomyPediatric Emergency Medicine (Emergency Medicine) Physician
License Number5426
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5426
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number20A15727
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: