Provider Demographics
NPI:1023898210
Name:PORTER, JACOB ALLEN
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ALLEN
Last Name:PORTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13351 CONQUER HILL RD
Mailing Address - Street 2:
Mailing Address - City:BYESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43723-9683
Mailing Address - Country:US
Mailing Address - Phone:740-801-2983
Mailing Address - Fax:
Practice Address - Street 1:65347 LAKE RD LOT B
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-8519
Practice Address - Country:US
Practice Address - Phone:740-801-2983
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-04
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHUT7864333747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant