Basic Information
| Provider Information | |||||||||
| NPI: | 1033461884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | JONATHON | ||||||||
| MiddleName: | DOUGLAS | ||||||||
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| Credential: | D.O | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3835 N FREEWAY BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958341954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165767900 | ||||||||
| FaxNumber: | 9162850338 | ||||||||
| Practice Location | |||||||||
| Address1: | 1420 ROCKY RIDGE DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956612835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167839697 | ||||||||
| FaxNumber: | 9167839721 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2012 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 20A12424 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.