Basic Information
| Provider Information | |||||||||
| NPI: | 1972908762 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | LARRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3613 E GOLDEN EAGLE RD | ||||||||
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| City: | EAGLE MOUNTAIN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840053866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356507021 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1034 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2014 | ||||||||
| LastUpdateDate: | 11/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | Behavioral Health & Social Service Providers | Counselor | 225X00000X | 11351103-4201 | UT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.