Healthcare Provider Details

I. General information

NPI: 1578983854
Provider Name (Legal Business Name): JESSICA MARIE BUTALA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA MARIE RICHARDSON DO

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 01/12/2020
Certification Date: 01/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 ATHERHOLT RD
LYNCHBURG VA
24501
US

IV. Provider business mailing address

2402 ATHERHOLT RD
LYNCHBURG VA
24501-2148
US

V. Phone/Fax

Practice location:
  • Phone: 434-947-5967
  • Fax:
Mailing address:
  • Phone: 434-947-5967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0102205632
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS019421
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0102205632
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberOSO19421
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: