Provider Demographics
NPI:1861542029
Name:BUCKLEY, JEAN PATRICE
Entity type:Individual
Prefix:
First Name:JEAN
Middle Name:PATRICE
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 FREMONT ST.
Mailing Address - Street 2:
Mailing Address - City:STEVENS PT
Mailing Address - State:WI
Mailing Address - Zip Code:54481
Mailing Address - Country:US
Mailing Address - Phone:715-346-4646
Mailing Address - Fax:
Practice Address - Street 1:910 FREMONT ST
Practice Address - Street 2:
Practice Address - City:STEVENS PT.
Practice Address - State:WI
Practice Address - Zip Code:54481
Practice Address - Country:US
Practice Address - Phone:715-346-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42966800Medicaid