Healthcare Provider Details

I. General information

NPI: 1043975832
Provider Name (Legal Business Name): CHARLES JEROME BUTLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2021
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34448 YUCAIPA BLVD
YUCAIPA CA
92399-2412
US

IV. Provider business mailing address

29090 OAK CREEK LN
HIGHLAND CA
92346-6836
US

V. Phone/Fax

Practice location:
  • Phone: 909-353-7547
  • Fax:
Mailing address:
  • Phone: 909-346-4733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: