Provider Demographics
NPI:1184243743
Name:BUTLER PUTT, JORDAN AXELLE
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:AXELLE
Last Name:BUTLER PUTT
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 1:24832 SW 114TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33032-6326
Mailing Address - Country:US
Mailing Address - Phone:305-562-1179
Mailing Address - Fax:
Practice Address - Street 1:24832 SW 114TH AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33032-6326
Practice Address - Country:US
Practice Address - Phone:305-562-1179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20-114956106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician