Provider Demographics
NPI:1295823847
Name:BUTLER, JENCINA M (DO)
Entity Type:Individual
Prefix:
First Name:JENCINA
Middle Name:M
Last Name:BUTLER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12518 NE AIRPORT WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-1090
Mailing Address - Country:US
Mailing Address - Phone:503-256-2992
Mailing Address - Fax:503-258-0717
Practice Address - Street 1:12518 NE AIRPORT WAY STE 110
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1090
Practice Address - Country:US
Practice Address - Phone:503-256-2992
Practice Address - Fax:503-258-0717
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2011-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002071207Q00000X
ORDO24488207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8449662Medicaid
210973OtherDEPT OF LABOR & INDUST
ORG8859148Medicaid
210973OtherDEPT OF LABOR & INDUST
ORR150420Medicare PIN
OR11959880Medicare UPIN
WA8449662Medicaid