Provider Demographics
NPI:1235795485
Name:BODINE, JESSICA ROSE (LAC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ROSE
Last Name:BODINE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ROSE
Other - Last Name:WALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:520 3RD ST NW
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:ND
Mailing Address - Zip Code:58401-2968
Mailing Address - Country:US
Mailing Address - Phone:701-253-6300
Mailing Address - Fax:701-253-6400
Practice Address - Street 1:520 3RD ST NW
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:ND
Practice Address - Zip Code:58401-2968
Practice Address - Country:US
Practice Address - Phone:701-253-6300
Practice Address - Fax:701-253-6400
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1853101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)