Provider Demographics
NPI:1790815413
Name:BODINE, JANE HOLLY (LCPC)
Entity Type:Individual
Prefix:MS
First Name:JANE
Middle Name:HOLLY
Last Name:BODINE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 E VAN BUREN AVENUE
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-5183
Mailing Address - Country:US
Mailing Address - Phone:630-416-3146
Mailing Address - Fax:630-554-1261
Practice Address - Street 1:114 E VAN BUREN AVENUE
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-5183
Practice Address - Country:US
Practice Address - Phone:630-416-3146
Practice Address - Fax:630-554-1261
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL02207935OtherBCBS