MEDICARE: MRS. HENRIETTA A PORTER-JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376J00000X	Homemaker		OH

General Provider Information

NPI Number	:	1790376614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HENRIETTA A PORTER-JACKSON

Provider Business Mailing Address
First Line	:	1400 EAST BLAKE AVENUE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43211
Country	:	US
Telephone Number	:	380-799-4502
Fax Number	:

Provider Business Practice Location Address
First Line	:	1007 MCCLELLAND AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43211-2915
Country	:	US
Telephone Number	:	740-851-7746
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2021
Last Update Date	:	09/26/2024

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Directions to “ MRS. HENRIETTA A PORTER-JACKSON ” Practice Location

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