Healthcare Provider Details

I. General information

NPI: 1609948868
Provider Name (Legal Business Name): JEANELLE H. PORTER P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 12/08/2020
Certification Date: 12/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N EAGLE CREEK DR
LEXINGTON KY
40509-1805
US

IV. Provider business mailing address

100 N EAGLE CREEK DR
LEXINGTON KY
40509-1805
US

V. Phone/Fax

Practice location:
  • Phone: 859-258-5073
  • Fax: 859-258-5074
Mailing address:
  • Phone: 859-258-5073
  • Fax: 859-258-5074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License NumberPT-001907
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT-001907
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-001907
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: