Healthcare Provider Details

I. General information

NPI: 1942938154
Provider Name (Legal Business Name): JAZMIN CLAUDIA PORTILLO LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 3RD AVE SE STE 206-02
ROCHESTER MN
55904-4619
US

IV. Provider business mailing address

300 3RD AVE SE STE 206-02
ROCHESTER MN
55904-4619
US

V. Phone/Fax

Practice location:
  • Phone: 507-906-0348
  • Fax:
Mailing address:
  • Phone: 507-906-0348
  • Fax: 507-322-1702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number32562
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: