Provider Demographics
NPI:1578329504
Name:HUGHES, JACKSON BODIE
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:BODIE
Last Name:HUGHES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:154 ROSEMARY AVE
Mailing Address - Street 2:
Mailing Address - City:HUBERT
Mailing Address - State:NC
Mailing Address - Zip Code:28539-3988
Mailing Address - Country:US
Mailing Address - Phone:801-205-0646
Mailing Address - Fax:
Practice Address - Street 1:2D RECONNAISSANCE BATTALION
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-440-7703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-27
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman