Healthcare Provider Details

I. General information

NPI: 1225100118
Provider Name (Legal Business Name): JACQUELYNE R BODEA PMHNP-BC, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 01/29/2022
Certification Date: 01/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 STONEFOREST DR STE 230
WOODSTOCK GA
30189-4903
US

IV. Provider business mailing address

10025 INVESTMENT DR STE 100
KNOXVILLE TN
37932-2665
US

V. Phone/Fax

Practice location:
  • Phone: 470-552-8470
  • Fax:
Mailing address:
  • Phone: 865-606-6110
  • Fax: 865-312-6442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN102394
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN102394
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: