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General NPI Number Information
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NPI Number | 1568823060
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Entity Type | Individual
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Provider Name | MR. JEFFERY PORTER
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Gender | Male
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Dates
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Enumeration Date | 03/10/2016
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Last Update Date | 01/16/2025
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Provider Practice Location Address
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Address Line | 1309 BENNETT AVE
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City | BURLEY
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State | ID
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Zip | 83318-2676
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Country | US
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Telephone | 208-678-7796
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Fax |
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Provider Business Mailing Address
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Address Line | 2350 OAKLEY AVE
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City | BURLEY
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State | ID
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Zip | 83318-2924
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Country | US
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Telephone | 208-831-6631
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LCSW-37640
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License Number State | ID
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