Provider Demographics
NPI:1174745814
Name:BUTZEL, JESSICA SOLKY (PHD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:SOLKY
Last Name:BUTZEL
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 1:12 LEIGHTON FARM RD
Mailing Address - Street 2:
Mailing Address - City:CAPE ELIZABETH
Mailing Address - State:ME
Mailing Address - Zip Code:04107-9704
Mailing Address - Country:US
Mailing Address - Phone:207-332-7670
Mailing Address - Fax:
Practice Address - Street 1:1226 SHORE RD
Practice Address - Street 2:
Practice Address - City:CAPE ELIZABETH
Practice Address - State:ME
Practice Address - Zip Code:04107-2123
Practice Address - Country:US
Practice Address - Phone:207-332-7670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1160103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME100529OtherBCBS PAYER NUMBER