Healthcare Provider Details

I. General information

NPI: 1326479411
Provider Name (Legal Business Name): JACQUELYNE BODLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2013
Last Update Date: 11/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N EUCLID AVE STE 551B
SAINT LOUIS MO
63108-1690
US

IV. Provider business mailing address

625 N EUCLID AVE STE 551B
SAINT LOUIS MO
63108-1690
US

V. Phone/Fax

Practice location:
  • Phone: 314-802-8080
  • Fax: 314-802-8082
Mailing address:
  • Phone: 314-802-8080
  • Fax: 314-802-8082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: