Provider Demographics
NPI:1538159512
Name:BUCCI, JACQUELINE L (MSSW)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:L
Last Name:BUCCI
Suffix:
Gender:F
Credentials:MSSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USA MEDDAC
Mailing Address - Street 2:11050 MT. BEVEDERE BLVD.
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5004
Mailing Address - Country:US
Mailing Address - Phone:315-772-1079
Mailing Address - Fax:315-772-9498
Practice Address - Street 1:USA MEDDAC
Practice Address - Street 2:11050 MOUNT BELVEDERE BLVD
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-5004
Practice Address - Country:US
Practice Address - Phone:315-772-4025
Practice Address - Fax:315-772-9498
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO250104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVAD000Medicare UPIN