Provider Demographics
NPI:1245572213
Name:BODE, JACQUELINE ANN (APN)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:BODE
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 JESSICA DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JACOB
Mailing Address - State:IL
Mailing Address - Zip Code:62281-1247
Mailing Address - Country:US
Mailing Address - Phone:618-444-5491
Mailing Address - Fax:618-551-3944
Practice Address - Street 1:205 W PARK AVE STE 103
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820-7888
Practice Address - Country:US
Practice Address - Phone:217-284-6236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277.002017363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily