=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396828992
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. JESSICA BLOOM BUCKLEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2006
-----------------------------------------------------
Last Update Date | 09/11/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3200 MACCORKLE AVE SE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-388-4077
-----------------------------------------------------
Fax | 304-388-9852
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 DAWN PLACE
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25314
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-344-0949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 61450
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 73554
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------