Healthcare Provider Details

I. General information

NPI: 1013832138
Provider Name (Legal Business Name): JAKOB LOGAN PORTER DPT, PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13039 WORLDGATE DR
HERNDON VA
20170-4374
US

IV. Provider business mailing address

12701 FAIR LAKES CIR STE 102
FAIRFAX VA
22033-4913
US

V. Phone/Fax

Practice location:
  • Phone: 703-689-3164
  • Fax: 703-689-3167
Mailing address:
  • Phone: 703-689-3164
  • Fax: 703-689-3167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305217930
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: