Provider Demographics
NPI:1659463123
Name:BODKIN, KATHLEEN GERSEK (RD, LD/N,CDE)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:GERSEK
Last Name:BODKIN
Suffix:
Gender:F
Credentials:RD, LD/N,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3972 PETITE DR W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32250-2206
Mailing Address - Country:US
Mailing Address - Phone:904-223-3586
Mailing Address - Fax:
Practice Address - Street 1:1350 13TH AVE S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3203
Practice Address - Country:US
Practice Address - Phone:904-627-2900
Practice Address - Fax:904-376-4925
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND498133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered