Provider Demographics
NPI:1033237961
Name:BUTLER, JACKIE M (CCS)
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:M
Last Name:BUTLER
Suffix:
Gender:F
Credentials:CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 HEATHERBROOK DR
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-9515
Mailing Address - Country:US
Mailing Address - Phone:336-880-0642
Mailing Address - Fax:
Practice Address - Street 1:5209 W WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-9177
Practice Address - Country:US
Practice Address - Phone:336-812-8645
Practice Address - Fax:336-812-8652
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC153101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6110523Medicaid