Provider Demographics
NPI:1902061500
Name:BUTLER, JENNIFER LYNN (SPEECH THERPAIST)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BUTLER
Suffix:
Gender:F
Credentials:SPEECH THERPAIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:KENOVA
Mailing Address - State:WV
Mailing Address - Zip Code:25530-1506
Mailing Address - Country:US
Mailing Address - Phone:304-453-2433
Mailing Address - Fax:304-453-1205
Practice Address - Street 1:748 BEECH ST
Practice Address - Street 2:
Practice Address - City:KENOVA
Practice Address - State:WV
Practice Address - Zip Code:25530-1506
Practice Address - Country:US
Practice Address - Phone:304-453-2433
Practice Address - Fax:304-453-1205
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-1047235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810012235Medicaid