Healthcare Provider Details

I. General information

NPI: 1962889477
Provider Name (Legal Business Name): JENNIFER LYNN PORTER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER JACKSON LSW

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 05/02/2023
Certification Date: 05/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 MCKINLEY AVE
KELLOGG ID
83837-2693
US

IV. Provider business mailing address

PO BOX 1387
HAYDEN ID
83835-1387
US

V. Phone/Fax

Practice location:
  • Phone: 208-783-1267
  • Fax: 844-807-3782
Mailing address:
  • Phone: 208-783-1267
  • Fax: 844-807-3782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-43510
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: