Provider Demographics
NPI:1043571169
Name:BUCKLEY, JESSICA JEAN (BSW)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:JEAN
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2421
Mailing Address - Country:US
Mailing Address - Phone:608-304-3553
Mailing Address - Fax:
Practice Address - Street 1:1407 SAINT ANDREW ST
Practice Address - Street 2:STE 100
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-3301
Practice Address - Country:US
Practice Address - Phone:608-789-4837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10976.120171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator