Healthcare Provider Details

I. General information

NPI: 1710369822
Provider Name (Legal Business Name): JEANNINE BUCKLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6521 ARLINGTON BLVD STE 312
FALLS CHURCH VA
22042-3009
US

IV. Provider business mailing address

224 E SKYLINE DR
PURCELLVILLE VA
20132-6123
US

V. Phone/Fax

Practice location:
  • Phone: 703-536-1817
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131000783
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: