Provider Demographics
NPI:1861875445
Name:BUCKLEY, JERI (DNP, ARNP, FNP-BC)
Entity type:Individual
Prefix:
First Name:JERI
Middle Name:
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:DNP, ARNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17120 KERCHEVAL AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1661
Mailing Address - Country:US
Mailing Address - Phone:313-886-3300
Mailing Address - Fax:313-417-1071
Practice Address - Street 1:17120 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE
Practice Address - State:MI
Practice Address - Zip Code:48230-1661
Practice Address - Country:US
Practice Address - Phone:313-886-3300
Practice Address - Fax:313-417-1071
Is Sole Proprietor?:No
Enumeration Date:2015-07-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704243688363LF0000X
FLARNP9301335363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015518900Medicaid
FLY0S9XOtherBCBS
FL015518900Medicaid