Provider Demographics
NPI:1023120177
Name:BUTLER, JACQUELINE (PHD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:BUTLER
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4180 MARIAN ST
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7426
Mailing Address - Country:US
Mailing Address - Phone:619-644-5750
Mailing Address - Fax:619-644-5751
Practice Address - Street 1:4700 SPRING ST
Practice Address - Street 2:SUITE 204
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5263
Practice Address - Country:US
Practice Address - Phone:619-644-5750
Practice Address - Fax:619-644-5751
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP1690103T00000X
CAPSY19513103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4385231OtherAETNA INSURANCE
CA8718236Medicaid
TN4106863OtherBLUE CROSS OF TN
TN4106863OtherBLUE CROSS OF TN
CAQ22288Medicare UPIN