Healthcare Provider Details

I. General information

NPI: 1386782993
Provider Name (Legal Business Name): JACQUELINE DENISE BUTLER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2007
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 COMMONWEALTH PL STE 232
VIRGINIA BEACH VA
23464-4517
US

IV. Provider business mailing address

900 COMMONWEALTH PL STE 232
VIRGINIA BEACH VA
23464-4517
US

V. Phone/Fax

Practice location:
  • Phone: 757-456-9205
  • Fax: 757-456-9209
Mailing address:
  • Phone: 757-456-9205
  • Fax: 757-456-9209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number090400640
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904006406
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0904006406
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number0904006406
License Number StateVA
# 5
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number0904006406
License Number StateVA
# 6
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number0904006406
License Number StateVA
# 7
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberPPS-0600412
License Number StateVA
# 8
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number0904006406
License Number StateVA
# 9
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number0904006406
License Number StateVA
# 10
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number0904006406
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: