Basic Information
| Provider Information | |||||||||
| NPI: | 1316570187 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 MALLORY CT | ||||||||
| Address2: | |||||||||
| City: | CENTRAL POINT | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975023747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417272830 | ||||||||
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| Practice Location | |||||||||
| Address1: | 821 SAGINAW ST S | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973024121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035894046 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2020 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | OR | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.