Doctor Name: | MISS JESSICA BROOKE PORTER |
NPI Number: | 1003926098 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | B.S, FAODP |
License Number: | |
Business Practice Address: | 1435 N Oakland Blvd Waterford, MI - 483271549 |
Business Phone Number: | 2486662720 |
Business Fax Number: | |
Mailing Address: | 1147 Ironwood Ct, Apt 004 ROCHESTER |
State: | MI |
Postal Code: | 483071261 |
Phone Number: | 2489090189 |
Fax Number: | |
NPI Enumeration Date: | 08/30/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 101YA0400X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Counselor |
Taxonomy Specialization: | Addiction (Substance Use Disorder) |
Taxonomy Definition: |