Provider Demographics
NPI:1871102996
Name:PORTER, JESSICA NICOLE JOHNSON (BCBA)
Entity type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:NICOLE JOHNSON
Last Name:PORTER
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:NICOLE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:542 AMHERST ST STE B
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03063-1016
Mailing Address - Country:US
Mailing Address - Phone:844-923-4222
Mailing Address - Fax:
Practice Address - Street 1:2615 MEDICAL CENTER PKWY STE 1580A
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-2261
Practice Address - Country:US
Practice Address - Phone:561-895-4496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2025-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1-21-48575103K00000X
1-21-48575103K00000X
0-20-11223106E00000X
TN1553103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
0-20-11223OtherBACB CERTIFICATION
SC1-21-48575OtherBACB CERTIFICATION
SCBB1074Medicaid