Provider Demographics
NPI:1417405317
Name:WALTER, JASON MICHAEL (LPCC, LADC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:WALTER
Suffix:
Gender:M
Credentials:LPCC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6656 PINE CREST TRL S
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55016-4679
Mailing Address - Country:US
Mailing Address - Phone:612-562-6766
Mailing Address - Fax:612-638-6601
Practice Address - Street 1:8530 EAGLE POINT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:LAKE ELMO
Practice Address - State:MN
Practice Address - Zip Code:55042-8648
Practice Address - Country:US
Practice Address - Phone:612-562-6766
Practice Address - Fax:612-638-6601
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-20
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN01898101YM0800X
MN304589101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)