Provider Demographics
NPI:1679662480
Name:PORTER, JEANETTE MARIE (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:JEANETTE
Middle Name:MARIE
Last Name:PORTER
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:MARIE
Other - Last Name:POWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:540 LAFAYETTE RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:SPARTA
Mailing Address - State:NJ
Mailing Address - Zip Code:07871-3497
Mailing Address - Country:US
Mailing Address - Phone:973-300-1553
Mailing Address - Fax:973-383-6236
Practice Address - Street 1:540 LAFAYETTE RD
Practice Address - Street 2:SUITE D
Practice Address - City:SPARTA
Practice Address - State:NJ
Practice Address - Zip Code:07871-3497
Practice Address - Country:US
Practice Address - Phone:973-300-1553
Practice Address - Fax:973-383-6236
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2009-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3500363A00000X, 363AS0400X
NJ25MP00223600363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant