Healthcare Provider Details

I. General information

NPI: 1992917694
Provider Name (Legal Business Name): JACKIE L BUELL PHD,RD, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 07/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 KENNY RD SPORTS MEDICINE, GYMNASIUM SPACE EXAM RM 1
COLUMBUS OH
43221-3502
US

IV. Provider business mailing address

2050 KENNY RD SPORTS MEDICINE, 3RD FLOOR
COLUMBUS OH
43221-3502
US

V. Phone/Fax

Practice location:
  • Phone: 614-293-3600
  • Fax:
Mailing address:
  • Phone: 614-293-3600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD.5999
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT000022
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: