MEDICARE: JESSICA L. OTTENWELLER-BUTCHER MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	01064357A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P01390392	OTHER	IN	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	000000615710	OTHER		BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1629089453
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA L. OTTENWELLER-BUTCHER MD

Provider Business Mailing Address
First Line	:	6920 POINTE INVERNESS WAY STE 200
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-7934
Country	:	US
Telephone Number	:	260-479-3516
Fax Number	:	260-479-3520

Provider Business Practice Location Address
First Line	:	2512 E DUPONT RD STE 200
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1609
Country	:	US
Telephone Number	:	260-458-3760
Fax Number	:	260-458-3761

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2006
Last Update Date	:	12/21/2020

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Directions to “ JESSICA L. OTTENWELLER-BUTCHER MD” Practice Location

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