Provider Demographics
NPI:1700308202
Name:BUCKNER, JAMIE JERROD (LSW)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:JERROD
Last Name:BUCKNER
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3999 FORT CAMPBELL BLVD
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42240-4929
Mailing Address - Country:US
Mailing Address - Phone:270-886-2205
Mailing Address - Fax:270-886-0392
Practice Address - Street 1:735 NORTH DR
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-2620
Practice Address - Country:US
Practice Address - Phone:270-886-5163
Practice Address - Fax:270-886-5178
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY252216104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker