Healthcare Provider Details

I. General information

NPI: 1336076413
Provider Name (Legal Business Name): JAKE PORTINGA MED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HUNDERTMARK RD
CHASKA MN
55318-4551
US

IV. Provider business mailing address

5828 MEADOW LAKE RD W
NEW HOPE MN
55428-3169
US

V. Phone/Fax

Practice location:
  • Phone: 952-361-2447
  • Fax:
Mailing address:
  • Phone: 952-381-7565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: