Healthcare Provider Details

I. General information

NPI: 1336760750
Provider Name (Legal Business Name): JASON MICHAEL PORTER LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2020
Last Update Date: 09/05/2026
Certification Date: 09/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

724 BIELENBERG DR # 108
WOODBURY MN
55125-2620
US

IV. Provider business mailing address

4718 ORDELL TRL N
STILLWATER MN
55082-7510
US

V. Phone/Fax

Practice location:
  • Phone: 612-670-1742
  • Fax: 651-390-6289
Mailing address:
  • Phone: 612-670-1742
  • Fax: 651-390-6289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCC02451
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: