Provider Demographics
NPI:1487635520
Name:BUCKLE, JACQUELINE NEYSA (MS)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:NEYSA
Last Name:BUCKLE
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3825 HENDERSON BLVD STE 401
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5022
Mailing Address - Country:US
Mailing Address - Phone:727-389-1667
Mailing Address - Fax:941-240-2160
Practice Address - Street 1:3825 HENDERSON BLVD STE 401
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5022
Practice Address - Country:US
Practice Address - Phone:727-389-1667
Practice Address - Fax:941-240-2160
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH7666101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health