Provider Demographics
NPI:1811278070
Name:BUCKLEY, JENNA ROSE (CD RD)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:ROSE
Last Name:BUCKLEY
Suffix:
Gender:F
Credentials:CD RD
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:ROSE
Other - Last Name:FORTIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3807 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53405-1667
Mailing Address - Country:US
Mailing Address - Phone:262-687-6339
Mailing Address - Fax:262-687-6345
Practice Address - Street 1:3807 SPRING ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53405-1667
Practice Address - Country:US
Practice Address - Phone:262-687-6339
Practice Address - Fax:262-687-6345
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2011-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2286133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered