Basic Information
| Provider Information | |||||||||
| NPI: | 1417342825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BUTLER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPCC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | A | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 SOUTHERN SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | SOMERSET | ||||||||
| State: | KY | ||||||||
| PostalCode: | 425013223 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 ADANTA CIR | ||||||||
| Address2: | |||||||||
| City: | ALBANY | ||||||||
| State: | KY | ||||||||
| PostalCode: | 426029549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6063877635 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2015 | ||||||||
| LastUpdateDate: | 11/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 00218279 | KY | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | 245521 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.