Healthcare Provider Details

I. General information

NPI: 1104730860
Provider Name (Legal Business Name): JEREMY PORTER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 RED COACH DR STE 107
MISHAWAKA IN
46545-3195
US

IV. Provider business mailing address

21649 MAPLE GLEN DR
EDWARDSBURG MI
49112-9718
US

V. Phone/Fax

Practice location:
  • Phone: 574-318-7800
  • Fax:
Mailing address:
  • Phone: 303-587-4893
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT22608995
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: