Provider Demographics
NPI:1629089453
Name:OTTENWELLER-BUTCHER, JESSICA L (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:OTTENWELLER-BUTCHER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:L
Other - Last Name:OTTENWELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3516
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:2512 E DUPONT RD STE 200
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1609
Practice Address - Country:US
Practice Address - Phone:260-458-3760
Practice Address - Fax:260-458-3761
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01064357A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200941590Medicaid
000000615710OtherBLUE CROSS BLUE SHIELD
INP01390392OtherRAILROAD MEDICARE
000000615710OtherBLUE CROSS BLUE SHIELD
INM400048102Medicare PIN
000000615710OtherBLUE CROSS BLUE SHIELD
IN925530KMedicare PIN