Provider Demographics
NPI:1639301310
Name:JUPITER CENTER, PLLC
Entity type:Organization
Organization Name:JUPITER CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KINZER
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:612-701-0064
Mailing Address - Street 1:2124 DUPONT AVE S
Mailing Address - Street 2:SUITE G1
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55405-2700
Mailing Address - Country:US
Mailing Address - Phone:612-701-0064
Mailing Address - Fax:612-605-3283
Practice Address - Street 1:2124 DUPONT AVE S
Practice Address - Street 2:SUITE G1
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2700
Practice Address - Country:US
Practice Address - Phone:612-701-0064
Practice Address - Fax:612-605-3283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-14
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1575106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN538977000Medicaid