Provider Demographics
NPI:1609417385
Name:BUTKIEWICZ, JORDAN (LPN)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:BUTKIEWICZ
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3520 WORLEY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-2564
Mailing Address - Country:US
Mailing Address - Phone:615-480-9614
Mailing Address - Fax:
Practice Address - Street 1:3427 MELROSE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-1608
Practice Address - Country:US
Practice Address - Phone:910-864-8739
Practice Address - Fax:910-864-8222
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC87847164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse