Provider Demographics
NPI:1790812824
Name:BODNARIK, JACKIE CHRISTINE
Entity Type:Individual
Prefix:
First Name:JACKIE
Middle Name:CHRISTINE
Last Name:BODNARIK
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 1:317 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-6725
Mailing Address - Country:US
Mailing Address - Phone:910-347-6009
Mailing Address - Fax:910-355-2267
Practice Address - Street 1:317 CENTER ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-6725
Practice Address - Country:US
Practice Address - Phone:910-347-6009
Practice Address - Fax:910-355-2267
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3418095Medicaid
NC8301307Medicaid