Provider Demographics
NPI:1932579315
Name:BUCKNER, JODY ALBERT (CNA)
Entity type:Individual
Prefix:MR
First Name:JODY
Middle Name:ALBERT
Last Name:BUCKNER
Suffix:
Gender:M
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 SHIRLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-7246
Mailing Address - Country:US
Mailing Address - Phone:318-730-7832
Mailing Address - Fax:
Practice Address - Street 1:1220 SHIRLAND AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-7246
Practice Address - Country:US
Practice Address - Phone:318-730-7832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA10636000#P8Q83172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker