Healthcare Provider Details

I. General information

NPI: 1245827302
Provider Name (Legal Business Name): JENNIFER PORTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/23/2020
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 INTERNATIONAL CIR STE 230
HUNT VALLEY MD
21030-1344
US

IV. Provider business mailing address

470 CRANES ROOST CT
ANNAPOLIS MD
21409-5748
US

V. Phone/Fax

Practice location:
  • Phone: 866-287-2036
  • Fax:
Mailing address:
  • Phone: 866-287-2036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: