Provider Demographics
NPI:1841299948
Name:BODDEN, JACQUELYNE ANNE (MSN RN-C WHNP)
Entity type:Individual
Prefix:MS
First Name:JACQUELYNE
Middle Name:ANNE
Last Name:BODDEN
Suffix:
Gender:F
Credentials:MSN RN-C WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1750
Mailing Address - Country:US
Mailing Address - Phone:608-348-7275
Mailing Address - Fax:
Practice Address - Street 1:216 S 3RD AVE
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4636
Practice Address - Country:US
Practice Address - Phone:800-246-5743
Practice Address - Fax:715-675-1819
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1476-033363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43973600Medicaid