Healthcare Provider Details

I. General information

NPI: 1982055588
Provider Name (Legal Business Name): JACQUELINE GRIFFO BUCKLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2016
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 COVENANT RD
COLUMBIA SC
29204-4216
US

IV. Provider business mailing address

1100 PRICE AVE
COLUMBIA SC
29201-1860
US

V. Phone/Fax

Practice location:
  • Phone: 803-787-3033
  • Fax:
Mailing address:
  • Phone: 803-487-1308
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number5835
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: