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General NPI Number Information
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NPI Number | 1104730860
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Entity Type | Individual
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Provider Name | JEREMY PORTER
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Gender | Male
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Dates
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Enumeration Date | 09/30/2026
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Last Update Date | 09/30/2026
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Provider Practice Location Address
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Address Line | 229 RED COACH DR STE 107
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City | MISHAWAKA
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State | IN
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Zip | 46545-3195
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Country | US
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Telephone | 574-318-7800
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Fax |
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Provider Business Mailing Address
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Address Line | 21649 MAPLE GLEN DR
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City | EDWARDSBURG
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State | MI
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Zip | 49112-9718
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Country | US
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Telephone | 303-587-4893
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT22608995
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License Number State | IN
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