Provider Demographics
NPI:1114759743
Name:BUTLER, JACK EDWARD
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:BUTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20150 SHERIFFS CV
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-8046
Mailing Address - Country:US
Mailing Address - Phone:206-619-0844
Mailing Address - Fax:
Practice Address - Street 1:5643 N ACADEMY BLVD
Practice Address - Street 2:
Practice Address - City:COLORADO SPGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3658
Practice Address - Country:US
Practice Address - Phone:720-316-9974
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTA.0015515225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant