Provider Demographics
NPI:1992547806
Name:BUTLER, JAKE
Entity type:Individual
Prefix:
First Name:JAKE
Middle Name:
Last Name:BUTLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2928 COUNTY ROAD 429
Mailing Address - Street 2:
Mailing Address - City:CLEBURNE
Mailing Address - State:TX
Mailing Address - Zip Code:76031-8767
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8941 ATLANTA AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-7121
Practice Address - Country:US
Practice Address - Phone:949-891-1287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-11
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA142097106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist