Basic Information
| Provider Information | |||||||||
| NPI: | 1649513979 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PORTER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DNP, CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207635123 | ||||||||
| FaxNumber: | 3207637883 | ||||||||
| Practice Location | |||||||||
| Address1: | 610 30TH AVE W | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563083426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3207632540 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2013 | ||||||||
| LastUpdateDate: | 08/08/2014 | ||||||||
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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 | 367A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 1649513979 | 01 | MN | NPI | OTHER | R-145018-3 | 01 | MN | RN LICENSE | OTHER | 1649513979 | 05 | MN | MEDICAID |