Provider Demographics
NPI:1851316665
Name:BUCKNER, JORETTA A (NP)
Entity Type:Individual
Prefix:
First Name:JORETTA
Middle Name:A
Last Name:BUCKNER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 GLYNN ST N
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-1192
Mailing Address - Country:US
Mailing Address - Phone:770-461-3431
Mailing Address - Fax:
Practice Address - Street 1:200 TRILITH PKWY STE 100
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-4462
Practice Address - Country:US
Practice Address - Phone:404-948-3019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2022-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN101831363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN232230FFFFMedicare UPIN