Provider Demographics
NPI:1629594957
Name:BUTLER, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 POLE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WISE
Mailing Address - State:VA
Mailing Address - Zip Code:24293-4333
Mailing Address - Country:US
Mailing Address - Phone:276-328-1712
Mailing Address - Fax:
Practice Address - Street 1:5401 POLE BRIDGE RD
Practice Address - Street 2:
Practice Address - City:WISE
Practice Address - State:VA
Practice Address - Zip Code:24293-4333
Practice Address - Country:US
Practice Address - Phone:276-328-1712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver