MEDICARE: JACK EDWARD BUTLER

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	225200000X	Physical Therapy Assistant	PTA.0015515	CO

General Provider Information

NPI Number	:	1114759743
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK EDWARD BUTLER

Provider Business Mailing Address
First Line	:	20150 SHERIFFS CV
Second Line	:
City	:	MONUMENT
State	:	CO
Zip	:	80132-8046
Country	:	US
Telephone Number	:	206-619-0844
Fax Number	:

Provider Business Practice Location Address
First Line	:	5643 N ACADEMY BLVD
Second Line	:
City	:	COLORADO SPGS
State	:	CO
Zip	:	80918-3658
Country	:	US
Telephone Number	:	720-316-9974
Fax Number	:

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

Provider Enumeration Date	:	08/14/2024
Last Update Date	:	08/14/2024

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