Provider Demographics
NPI:1780782375
Name:BODE, JACQUELYN ELLEN (MED)
Entity type:Individual
Prefix:
First Name:JACQUELYN
Middle Name:ELLEN
Last Name:BODE
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:RUTLAND
Mailing Address - State:VT
Mailing Address - Zip Code:05701-4046
Mailing Address - Country:US
Mailing Address - Phone:802-747-3488
Mailing Address - Fax:802-747-0006
Practice Address - Street 1:73 CENTER ST
Practice Address - Street 2:
Practice Address - City:RUTLAND
Practice Address - State:VT
Practice Address - Zip Code:05701-4046
Practice Address - Country:US
Practice Address - Phone:802-747-3488
Practice Address - Fax:802-747-0006
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT291101YA0400X
VT269103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0002611Medicaid