Provider Demographics
NPI:1366869059
Name:BUCK, JAMIE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:BUCK
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 1:32926 BROOKSIDE CIR
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1419
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32926 BROOKSIDE CIR
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1419
Practice Address - Country:US
Practice Address - Phone:248-444-6287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201008361225X00000X
WAOT60441849225X00000X
HIOT1335225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist