Provider Demographics
NPI:1619219789
Name:TIMBERLAKE, JODIE K
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:K
Last Name:TIMBERLAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 5TH ST BLDG 840
Mailing Address - Street 2:
Mailing Address - City:WRIGHT PATTERSON AFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433-7951
Mailing Address - Country:US
Mailing Address - Phone:937-938-3630
Mailing Address - Fax:
Practice Address - Street 1:2325 5TH ST BLDG 675
Practice Address - Street 2:
Practice Address - City:WRIGHT PATTERSON AFB
Practice Address - State:OH
Practice Address - Zip Code:45433-7505
Practice Address - Country:US
Practice Address - Phone:937-257-0837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0101257066171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program