Provider Demographics
NPI:1104556638
Name:BUCCO, JESSICA R
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:R
Last Name:BUCCO
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 1:1796 KALE ADAMS RD SW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-9716
Mailing Address - Country:US
Mailing Address - Phone:330-610-7361
Mailing Address - Fax:
Practice Address - Street 1:1796 KALE ADAMS RD SW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-9716
Practice Address - Country:US
Practice Address - Phone:330-610-7361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-16
Last Update Date:2022-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSM914651175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist