Provider Demographics
NPI:1104805332
Name:BUCKNER, JEREMY RAY (DC)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:RAY
Last Name:BUCKNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11180
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-0020
Mailing Address - Country:US
Mailing Address - Phone:480-897-3300
Mailing Address - Fax:480-897-3312
Practice Address - Street 1:4540 E BASELINE RD STE 105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4616
Practice Address - Country:US
Practice Address - Phone:480-819-0393
Practice Address - Fax:480-536-9170
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4180111NR0400X
AZ7490111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation