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NPI Code Detail

MEDICARE: JACOB LARRY BUTLER

MEDICARE: JACOB LARRY 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
1101Y00000XCounselor
2225X00000XOccupational Therapist11351103-4201UT

General Provider Information

NPI Number : 1972908762
Entity Type Code : Individual
Provider Name (Legal Business Name) : JACOB LARRY BUTLER
Provider Business Mailing Address
First Line : 3613 E GOLDEN EAGLE RD
Second Line :
City : EAGLE MOUNTAIN
State : UT
Zip : 84005-3866
Country : US
Telephone Number : 435-650-7021
Fax Number :
Provider Business Practice Location Address
First Line : 1034 N 500 W
Second Line :
City : PROVO
State : UT
Zip : 84604-3337
Country : US
Telephone Number : 801-357-7850
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/23/2014
Last Update Date : 11/08/2021

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