Provider Demographics
NPI:1003220799
Name:BUTANIS, JESSICA M (DO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:M
Last Name:BUTANIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:610 30TH AVENUE WEST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:MN
Mailing Address - Zip Code:56308
Mailing Address - Country:US
Mailing Address - Phone:320-763-5123
Mailing Address - Fax:320-763-7883
Practice Address - Street 1:610 30TH AVE W
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:MN
Practice Address - Zip Code:56308-3426
Practice Address - Country:US
Practice Address - Phone:320-763-5123
Practice Address - Fax:320-763-7883
Is Sole Proprietor?:No
Enumeration Date:2014-06-20
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN61656207R00000X
IAR10068207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400413191OtherMEDICARE
MN1003220799Medicaid