Provider Demographics
NPI:1619458080
Name:BUTLER, JENNIE LAUREN (PHD, RDN, LDN)
Entity Type:Individual
Prefix:DR
First Name:JENNIE
Middle Name:LAUREN
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PHD, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTIC BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32233-3461
Mailing Address - Country:US
Mailing Address - Phone:919-951-4345
Mailing Address - Fax:
Practice Address - Street 1:1900 CORPORATE SQUARE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1941
Practice Address - Country:US
Practice Address - Phone:919-951-4345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL8749133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered