Provider Demographics
NPI:1083278212
Name:BODARY, JESSICA LYN (MPO, CPO)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:BODARY
Suffix:
Gender:F
Credentials:MPO, CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4117 IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-1805
Mailing Address - Country:US
Mailing Address - Phone:517-528-7549
Mailing Address - Fax:
Practice Address - Street 1:895 THIRD AVE BLDG 2
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-1304
Practice Address - Country:US
Practice Address - Phone:619-585-8421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO04202224P00000X, 222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist