Provider Demographics
NPI:1700366606
Name:BUCKELEW, JAIME LYNN (CSFA)
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:LYNN
Last Name:BUCKELEW
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 KENNESAW AVE NW STE 120
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1052
Mailing Address - Country:US
Mailing Address - Phone:678-556-5138
Mailing Address - Fax:770-336-6620
Practice Address - Street 1:800 KENNESAW AVE NW STE 120
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1052
Practice Address - Country:US
Practice Address - Phone:678-556-5138
Practice Address - Fax:770-336-6620
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-20
Last Update Date:2018-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA164724246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant