=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811278070
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNA ROSE BUCKLEY CD RD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/01/2011
-----------------------------------------------------
Last Update Date | 09/01/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3807 SPRING ST
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53405-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-687-6339
-----------------------------------------------------
Fax | 262-687-6345
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3807 SPRING ST
-----------------------------------------------------
City | MOUNT PLEASANT
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53405-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-687-6339
-----------------------------------------------------
Fax | 262-687-6345
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 2286
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------