Healthcare Provider Details

I. General information

NPI: 1245599851
Provider Name (Legal Business Name): JENNIFER ANN BUTLER L.I.C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER ANN MAGES

II. Dates (important events)

Enumeration Date: 05/16/2012
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MARSH ST
MANKATO MN
56001-4752
US

IV. Provider business mailing address

1025 MARSH ST PO BOX 8673
MANKATO MN
56001-4752
US

V. Phone/Fax

Practice location:
  • Phone: 507-385-6598
  • Fax: 507-385-4773
Mailing address:
  • Phone: 507-385-6598
  • Fax: 507-385-4773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20867
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: