Provider Demographics
NPI:1609023902
Name:BUCKLEY, ROSE JACKSON (HSPP)
Entity Type:Individual
Prefix:DR
First Name:ROSE
Middle Name:JACKSON
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5134 MCHENRY LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46228-2368
Mailing Address - Country:US
Mailing Address - Phone:812-322-5620
Mailing Address - Fax:
Practice Address - Street 1:3921 N MERIDIAN ST STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4064
Practice Address - Country:US
Practice Address - Phone:812-332-1262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
IN20043544B103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool