Provider Demographics
NPI:1275276602
Name:BUTLER, JORDAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11133 I-45 S.
Mailing Address - Street 2:SUITE 190
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77302
Mailing Address - Country:US
Mailing Address - Phone:936-494-0570
Mailing Address - Fax:936-494-0571
Practice Address - Street 1:11133 I-45 S.
Practice Address - Street 2:SUITE 190
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77302
Practice Address - Country:US
Practice Address - Phone:936-494-0570
Practice Address - Fax:936-494-0571
Is Sole Proprietor?:No
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX122563225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist