Provider Demographics
NPI:1851471999
Name:BODART, JENNIFER JEAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:JEAN
Last Name:BODART
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 W PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762-6602
Mailing Address - Country:US
Mailing Address - Phone:571-230-6864
Mailing Address - Fax:
Practice Address - Street 1:1060 W PERIMETER RD
Practice Address - Street 2:
Practice Address - City:JB ANDREWS
Practice Address - State:MD
Practice Address - Zip Code:20762-6602
Practice Address - Country:US
Practice Address - Phone:570-230-6864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2443-57103TH0004X
WI2443-53103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth