Provider Demographics
NPI:1386041176
Name:BUCKNER, JACQULINE
Entity Type:Individual
Prefix:MISS
First Name:JACQULINE
Middle Name:
Last Name:BUCKNER
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 1:125 NORTH ST
Mailing Address - Street 2:P.O. BOX 8003
Mailing Address - City:BELLEVUE
Mailing Address - State:OH
Mailing Address - Zip Code:44811-1423
Mailing Address - Country:US
Mailing Address - Phone:419-484-5003
Mailing Address - Fax:
Practice Address - Street 1:125 NORTH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:OH
Practice Address - Zip Code:44811-1423
Practice Address - Country:US
Practice Address - Phone:419-484-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-24
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH1519410171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator