Provider Demographics
NPI:1992917694
Name:BUELL, JACKIE L (PHD,RD, ATC)
Entity type:Individual
Prefix:DR
First Name:JACKIE
Middle Name:L
Last Name:BUELL
Suffix:
Gender:F
Credentials:PHD,RD, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 KENNY RD
Mailing Address - Street 2:SPORTS MEDICINE, 3RD FLOOR
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-3502
Mailing Address - Country:US
Mailing Address - Phone:614-293-3600
Mailing Address - Fax:
Practice Address - Street 1:2050 KENNY RD
Practice Address - Street 2:SPORTS MEDICINE, GYMNASIUM SPACE EXAM RM 1
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-3502
Practice Address - Country:US
Practice Address - Phone:614-293-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0000222255A2300X
OHLD.5999133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer