Provider Demographics
NPI:1023256112
Name:BUTLER, JENNY MEGAN (PT)
Entity type:Individual
Prefix:
First Name:JENNY
Middle Name:MEGAN
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11073 BRANDING IRON LN
Mailing Address - Street 2:
Mailing Address - City:ROSCOE
Mailing Address - State:IL
Mailing Address - Zip Code:61073-8189
Mailing Address - Country:US
Mailing Address - Phone:815-222-4481
Mailing Address - Fax:
Practice Address - Street 1:5510 E. STATE ST.
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2381
Practice Address - Country:US
Practice Address - Phone:815-395-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-27
Last Update Date:2019-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070013640225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist