Provider Demographics
NPI:1043575202
Name:BODDEN, JACQUELINE
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:
Last Name:BODDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1874 PELHAM PKWY S APT 6N
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-3750
Mailing Address - Country:US
Mailing Address - Phone:917-517-2629
Mailing Address - Fax:
Practice Address - Street 1:1874 PELHAM PKWY S APT 6N
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-3750
Practice Address - Country:US
Practice Address - Phone:917-517-2629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY561048051252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency