Provider Demographics
NPI:1093978629
Name:BUCHANAN, JACQUELINE J
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:J
Last Name:BUCHANAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2038 N 41 ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66104-3535
Mailing Address - Country:US
Mailing Address - Phone:913-287-8304
Mailing Address - Fax:866-441-6055
Practice Address - Street 1:2038 N 41 ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66104-3535
Practice Address - Country:US
Practice Address - Phone:913-287-8304
Practice Address - Fax:866-441-6055
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSB105115311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200306540AMedicaid