MEDICARE: DR. JAEE BODAS PH.D. LCP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC2200X	Clinical Child & Adolescent Psychologist	0810003928	VA

General Provider Information

NPI Number	:	1841450053
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAEE BODAS PH.D. LCP

Provider Business Mailing Address
First Line	:	11805 COOLWIND LN
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23233-1788
Country	:	US
Telephone Number	:	804-402-1513
Fax Number	:	804-533-5313

Provider Business Practice Location Address
First Line	:	5230 HICKORY PARK DR STE A
Second Line	:
City	:	GLEN ALLEN
State	:	VA
Zip	:	23059-2628
Country	:	US
Telephone Number	:	804-402-1513
Fax Number	:	804-533-5313

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2008
Last Update Date	:	03/12/2026

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