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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:855-832-6727
Mailing Address - Fax:772-657-9100
Practice Address - Street 1:7108 SOUTH KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7462
Practice Address - Country:US
Practice Address - Phone:856-832-6727
Practice Address - Fax:772-675-9100
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0-20-11223106E00000X
1-21-48575103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1-21-48575OtherBACB CERTIFICATION
SCBB1074Medicaid
0-20-11223OtherBACB CERTIFICATION