Provider Demographics
NPI:1518246628
Name:BUCKLEY, JACQUELINE RENEE (DPM)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:RENEE
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13030 121ST WAY NE
Mailing Address - Street 2:#204
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-3008
Mailing Address - Country:US
Mailing Address - Phone:404-808-4486
Mailing Address - Fax:
Practice Address - Street 1:13030 121ST WAY NE
Practice Address - Street 2:#204
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3008
Practice Address - Country:US
Practice Address - Phone:404-808-4486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-07
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO60311158213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery