Provider Demographics
NPI:1225786197
Name:LUCABAUGH, JESSE MICHAEL
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:MICHAEL
Last Name:LUCABAUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1519 AVONDALE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23227-4027
Mailing Address - Country:US
Mailing Address - Phone:804-661-8799
Mailing Address - Fax:
Practice Address - Street 1:2601 WILLARD RD STE 105
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294-3638
Practice Address - Country:US
Practice Address - Phone:046-661-8799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-10
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0133002336103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst