Provider Demographics
NPI:1386782993
Name:BUTLER, JACQUELINE DENISE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:DENISE
Last Name:BUTLER
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 COMMONWEALTH PL STE 232
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-4517
Mailing Address - Country:US
Mailing Address - Phone:757-456-9205
Mailing Address - Fax:757-456-9209
Practice Address - Street 1:900 COMMONWEALTH PL STE 232
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-4517
Practice Address - Country:US
Practice Address - Phone:757-456-9205
Practice Address - Fax:757-456-9209
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-03
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA090400640251S00000X
VA09040064061041C0700X, 101Y00000X, 101YM0800X, 101YP1600X, 101YS0200X, 106H00000X, 251B00000X, 104100000X
VAPPS-0600412101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No251B00000XAgenciesCase Management
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1386782993Medicaid
00Y172V01Medicare PIN