Provider Demographics
NPI:1396828992
Name:BUCKLEY, JESSICA BLOOM
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:BLOOM
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANNE
Other - Last Name:BLOOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3 DAWN PLACE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314
Mailing Address - Country:US
Mailing Address - Phone:304-344-0949
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304
Practice Address - Country:US
Practice Address - Phone:304-388-4077
Practice Address - Fax:304-388-9852
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV61450163W00000X
WV73554367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVP00274757OtherR MEDICARE
WV3810004241Medicaid
WV3810004241Medicaid