Provider Demographics
NPI:1225100118
Name:BODEA, JACQUELYNE R (PMHNP-BC, CNM)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYNE
Middle Name:R
Last Name:BODEA
Suffix:
Gender:F
Credentials:PMHNP-BC, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10025 INVESTMENT DR STE 100
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37932-2665
Mailing Address - Country:US
Mailing Address - Phone:865-606-6110
Mailing Address - Fax:865-312-6442
Practice Address - Street 1:100 STONEFOREST DR STE 230
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-4903
Practice Address - Country:US
Practice Address - Phone:470-552-8470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2022-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN102394367A00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife