Provider Demographics
NPI:1053508358
Name:PORTER, JENNIFER (PTA)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 WOODWARD
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA
Mailing Address - State:AR
Mailing Address - Zip Code:71753-2132
Mailing Address - Country:US
Mailing Address - Phone:870-904-6581
Mailing Address - Fax:
Practice Address - Street 1:155 S ADAMS AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:AR
Practice Address - Zip Code:71701-4031
Practice Address - Country:US
Practice Address - Phone:870-498-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR2107225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant