Healthcare Provider Details

I. General information

NPI: 1437598372
Provider Name (Legal Business Name): JESSICA FARLEY BODE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2013
Last Update Date: 06/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 WELCH RD
PALO ALTO CA
94304-1601
US

IV. Provider business mailing address

1139 CRESPI DR
PACIFICA CA
94044-3516
US

V. Phone/Fax

Practice location:
  • Phone: 650-497-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22067
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number696527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: