Provider Demographics
NPI:1447493721
Name:PORTER, JENNIFER SHELLY (LAC)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:SHELLY
Last Name:PORTER
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21154
Mailing Address - Street 2:
Mailing Address - City:BILLINGS
Mailing Address - State:MT
Mailing Address - Zip Code:59104-1154
Mailing Address - Country:US
Mailing Address - Phone:406-671-7399
Mailing Address - Fax:
Practice Address - Street 1:208 N 29TH ST
Practice Address - Street 2:SUITE 236-237
Practice Address - City:BILLINGS
Practice Address - State:MT
Practice Address - Zip Code:59101-1985
Practice Address - Country:US
Practice Address - Phone:406-671-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-15
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1203101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)