Provider Demographics
NPI:1508740085
Name:PORTER, JENNIFER (MDA, RDN, CD, IBCLC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:PORTER
Suffix:
Gender:F
Credentials:MDA, RDN, CD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1581 E WATERBURY DR UNIT G
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-1134
Mailing Address - Country:US
Mailing Address - Phone:208-286-5415
Mailing Address - Fax:
Practice Address - Street 1:1581 E WATERBURY DR UNIT G
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-1134
Practice Address - Country:US
Practice Address - Phone:208-286-5415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-05
Last Update Date:2025-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT86083279133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered