Provider Demographics
NPI:1972226793
Name:PORTILLO, JONATHAN MICHAEL (LPC)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:MICHAEL
Last Name:PORTILLO
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12609 ZUNI ST APT 304
Mailing Address - Street 2:
Mailing Address - City:BROOMFIELD
Mailing Address - State:CO
Mailing Address - Zip Code:80020-3825
Mailing Address - Country:US
Mailing Address - Phone:480-206-5524
Mailing Address - Fax:
Practice Address - Street 1:80 GARDEN CTR STE 48
Practice Address - Street 2:
Practice Address - City:BROOMFIELD
Practice Address - State:CO
Practice Address - Zip Code:80020-1777
Practice Address - Country:US
Practice Address - Phone:720-336-0675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0018678101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional