Provider Demographics
NPI:1194508648
Name:BODAGER, JESSICA KAY
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:KAY
Last Name:BODAGER
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 1:9309 PERSIMMON BROOK TRL APT 6-215
Mailing Address - Street 2:
Mailing Address - City:THONOTOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:33592-3898
Mailing Address - Country:US
Mailing Address - Phone:330-465-2898
Mailing Address - Fax:
Practice Address - Street 1:13000 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4745
Practice Address - Country:US
Practice Address - Phone:813-972-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT40535390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program