Provider Demographics
NPI:1225481716
Name:BUTLER, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
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 1:2092 OMEGA RD STE G
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1230
Mailing Address - Country:US
Mailing Address - Phone:415-637-7616
Mailing Address - Fax:
Practice Address - Street 1:2092 OMEGA RD STE G
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1230
Practice Address - Country:US
Practice Address - Phone:415-637-7616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3486224Z00000X
CA24132355S0801X
CA240169349252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant