Provider Demographics
NPI:1184176091
Name:BUTLER, JACOB ELI (LPC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ELI
Last Name:BUTLER
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:CANADIAN
Mailing Address - State:OK
Mailing Address - Zip Code:74425-9750
Mailing Address - Country:US
Mailing Address - Phone:405-430-3030
Mailing Address - Fax:
Practice Address - Street 1:100 DIVISION ST
Practice Address - Street 2:
Practice Address - City:CANADIAN
Practice Address - State:OK
Practice Address - Zip Code:74425-9750
Practice Address - Country:US
Practice Address - Phone:405-430-3030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-26
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKBACU03012013-1171100000X
OK101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No171100000XOther Service ProvidersAcupuncturist