Healthcare Provider Details

I. General information

NPI: 1295823847
Provider Name (Legal Business Name): JENCINA M BUTLER DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 11/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12518 NE AIRPORT WAY STE 110
PORTLAND OR
97230-1090
US

IV. Provider business mailing address

12518 NE AIRPORT WAY STE 110
PORTLAND OR
97230-1090
US

V. Phone/Fax

Practice location:
  • Phone: 503-256-2992
  • Fax: 503-258-0717
Mailing address:
  • Phone: 503-256-2992
  • Fax: 503-258-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP00002071
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO24488
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: