Basic Information
| Provider Information | |||||||||
| NPI: | 1497779268 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | MA, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 CHESTNUT CREEK DR | ||||||||
| Address2: | |||||||||
| City: | APOPKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327034866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072600551 | ||||||||
| FaxNumber: | 4072659590 | ||||||||
| Practice Location | |||||||||
| Address1: | 1060 W STATE ROAD 434 | ||||||||
| Address2: | SUITE 108 | ||||||||
| City: | LONGWOOD | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327504919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072600551 | ||||||||
| FaxNumber: | 4072659590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA7021 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 888846900 | 05 | FL | MEDICAID |