Provider Demographics
NPI:1114315835
Name:BUCKMAN, JENNIFER (COTA/L)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:BUCKMAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:THORNTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:408 NORTHGATE RD
Mailing Address - Street 2:
Mailing Address - City:FAIRDALE
Mailing Address - State:KY
Mailing Address - Zip Code:40118-8722
Mailing Address - Country:US
Mailing Address - Phone:502-802-1729
Mailing Address - Fax:
Practice Address - Street 1:10 S 9TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-2630
Practice Address - Country:US
Practice Address - Phone:317-204-3736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYBOTOTA00210714224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant