Provider Demographics
NPI:1982622643
Name:BODLEY, JENNIFER LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:BODLEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8104 N WAYWARD STAR DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743-7354
Mailing Address - Country:US
Mailing Address - Phone:325-245-7626
Mailing Address - Fax:
Practice Address - Street 1:9615 E OLD SPANISH TRL
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85748-7540
Practice Address - Country:US
Practice Address - Phone:520-546-1766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1829152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD150309ZDF8Medicare PIN