Healthcare Provider Details

I. General information

NPI: 1407005200
Provider Name (Legal Business Name): JEREMY DEAN PORTER LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1486 ELECTRIC AVE SUITE #103
BELLINGHAM WA
98229-2410
US

IV. Provider business mailing address

2810 W INDIANA ST #1
BELLINGHAM WA
98225-1509
US

V. Phone/Fax

Practice location:
  • Phone: 360-671-5644
  • Fax:
Mailing address:
  • Phone: 360-224-8845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMA00013632
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: