Basic Information
| Provider Information | |||||||||
| NPI: | 1053784447 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUCKNER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | LAYMAN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232856647 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 NEWPORT TOWNE CTR | ||||||||
| Address2: | |||||||||
| City: | NEWPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378217360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236232890 | ||||||||
| FaxNumber: | 4236232924 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2015 | ||||||||
| LastUpdateDate: | 11/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5711 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.