Healthcare Provider Details

I. General information

NPI: 1568823060
Provider Name (Legal Business Name): MR. JEFFERY PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 01/16/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1309 BENNETT AVE
BURLEY ID
83318-2676
US

IV. Provider business mailing address

2350 OAKLEY AVE
BURLEY ID
83318-2924
US

V. Phone/Fax

Practice location:
  • Phone: 208-678-7796
  • Fax:
Mailing address:
  • Phone: 208-831-6631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-37640
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: