=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972226793
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN MICHAEL PORTILLO LPC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2022
-----------------------------------------------------
Last Update Date | 09/26/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 80 GARDEN CTR STE 48
-----------------------------------------------------
City | BROOMFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80020-1777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-336-0675
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12609 ZUNI ST APT 304
-----------------------------------------------------
City | BROOMFIELD
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80020-3825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-206-5524
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC.0018678
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------