Healthcare Provider Details

I. General information

NPI: 1609023902
Provider Name (Legal Business Name): ROSE JACKSON BUCKLEY HSPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 10/20/2022
Certification Date: 10/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3921 N MERIDIAN ST STE 200
INDIANAPOLIS IN
46208-4064
US

IV. Provider business mailing address

5134 MCHENRY LN
INDIANAPOLIS IN
46228-2368
US

V. Phone/Fax

Practice location:
  • Phone: 812-332-1262
  • Fax:
Mailing address:
  • Phone: 812-322-5620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20043544B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: