Healthcare Provider Details

I. General information

NPI: 1245572213
Provider Name (Legal Business Name): JACQUELINE ANN BODE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2013
Last Update Date: 05/01/2023
Certification Date: 05/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W PARK AVE STE 103
CHAMPAIGN IL
61820-7888
US

IV. Provider business mailing address

177 JESSICA DR
SAINT JACOB IL
62281-1247
US

V. Phone/Fax

Practice location:
  • Phone: 217-284-6236
  • Fax:
Mailing address:
  • Phone: 618-444-5491
  • Fax: 618-551-3944

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number277.002017
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number277.002017
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: