Provider Demographics
NPI:1003146168
Name:JACKSON, BERNICE BODDIE (MD)
Entity Type:Individual
Prefix:DR
First Name:BERNICE
Middle Name:BODDIE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 19788
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-0788
Mailing Address - Country:US
Mailing Address - Phone:323-938-6586
Mailing Address - Fax:
Practice Address - Street 1:241 N. FIGUEROA ST.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-2601
Practice Address - Country:US
Practice Address - Phone:213-989-7168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-12
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG370012083X0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational Medicine