Provider Demographics
NPI:1538989264
Name:BUTLER, JUSTIN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4153 FISHING CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:FL
Mailing Address - Zip Code:32068-3986
Mailing Address - Country:US
Mailing Address - Phone:904-210-4701
Mailing Address - Fax:
Practice Address - Street 1:1542 KINGSLEY AVE STE 136-137
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-4586
Practice Address - Country:US
Practice Address - Phone:239-690-6906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11035870363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health