=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063633261
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER KELLY BUTOW MSW, LCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 71 W MAIN ST SUITE 205
-----------------------------------------------------
City | FREEHOLD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07728-2138
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-294-7870
-----------------------------------------------------
Fax | 732-714-0924
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 709 GROVE ST
-----------------------------------------------------
City | POINT PLEASANT BEACH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08742-2515
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-892-8709
-----------------------------------------------------
Fax | 732-714-0924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 44SC00845500
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------