Provider Demographics
NPI:1699052084
Name:BUTLER, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
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 1:8432 GASKIN RD
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-9252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:43 OSWEGO ST STE 100
Practice Address - Street 2:
Practice Address - City:BALDWINSVILLE
Practice Address - State:NY
Practice Address - Zip Code:13027-2425
Practice Address - Country:US
Practice Address - Phone:315-320-6208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-14
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
NY087227-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16-1129675Medicaid