Provider Demographics
NPI:1275518144
Name:BUCKNER, JESSICA L (DPM)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:L
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 2100
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2690
Mailing Address - Country:US
Mailing Address - Phone:207-725-4008
Mailing Address - Fax:207-725-5749
Practice Address - Street 1:81 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 2100
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2690
Practice Address - Country:US
Practice Address - Phone:207-725-4008
Practice Address - Fax:207-725-5749
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPOD 1056213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431916399Medicaid
ME0915250001Medicare NSC
MEV06155Medicare UPIN
ME431916399Medicaid
MELX5408Medicare UPIN