Healthcare Provider Details

I. General information

NPI: 1396199048
Provider Name (Legal Business Name): JESSICA LYNN BODEA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 05/20/2025
Certification Date: 05/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 E BASELINE RD STE 125
MESA AZ
85206-4679
US

IV. Provider business mailing address

2108 E THOMAS RD STE 130
PHOENIX AZ
85016-0008
US

V. Phone/Fax

Practice location:
  • Phone: 480-839-4848
  • Fax: 480-833-8310
Mailing address:
  • Phone: 602-933-3124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number59850
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number70030
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number70030
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: