Provider Demographics
NPI:1861996944
Name:BODEKER, JENA R (RDN,LD)
Entity type:Individual
Prefix:
First Name:JENA
Middle Name:R
Last Name:BODEKER
Suffix:
Gender:F
Credentials:RDN,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 CORSICANA ST
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:TX
Mailing Address - Zip Code:76645-3037
Mailing Address - Country:US
Mailing Address - Phone:512-964-6151
Mailing Address - Fax:
Practice Address - Street 1:318 CORSICANA ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:TX
Practice Address - Zip Code:76645-3037
Practice Address - Country:US
Practice Address - Phone:512-964-6151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX951750133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered