Provider Demographics
NPI:1417913740
Name:BUCKLEY, JANE (APRN)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2365
Mailing Address - Country:US
Mailing Address - Phone:203-745-6202
Mailing Address - Fax:203-234-0801
Practice Address - Street 1:100 BROADWAY
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2365
Practice Address - Country:US
Practice Address - Phone:203-234-0365
Practice Address - Fax:203-234-0801
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2015-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002431363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P2528334OtherOXFORD
CT1932350105OtherGROUP INDENIFIER
298056OtherMHN
454047OtherVALUE OPTIONS
CT400002431CT02OtherANTHEM
2208919OtherCIGNA
P2528334OtherOXFORD
P39873Medicare UPIN