Provider Demographics
NPI:1982639878
Name:BUTLER, JENNIFER E (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9797 N GLEN HOLLOW LN
Mailing Address - Street 2:
Mailing Address - City:HAUSER
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6159
Mailing Address - Country:US
Mailing Address - Phone:208-771-3579
Mailing Address - Fax:208-561-6194
Practice Address - Street 1:9797 N GLEN HOLLOW LN
Practice Address - Street 2:
Practice Address - City:HAUSER
Practice Address - State:ID
Practice Address - Zip Code:83854-6159
Practice Address - Country:US
Practice Address - Phone:208-771-3579
Practice Address - Fax:208-561-6194
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-2037225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1651155OtherMEDICARE ID