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General NPI Number Information
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NPI Number | 1336076413
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Entity Type | Individual
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Provider Name | JAKE PORTINGA MED
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Gender | Male
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Dates
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Enumeration Date | 05/05/2026
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Last Update Date | 05/05/2026
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Provider Practice Location Address
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Address Line | 111 HUNDERTMARK RD
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City | CHASKA
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State | MN
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Zip | 55318-4551
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Country | US
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Telephone | 952-361-2447
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Fax |
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Provider Business Mailing Address
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Address Line | 5828 MEADOW LAKE RD W
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City | NEW HOPE
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State | MN
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Zip | 55428-3169
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Country | US
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Telephone | 952-381-7565
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2251S0007X
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Taxonomy Name | Sports Physical Therapist
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License Number |
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License Number State | MN
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