Basic Information
| Provider Information | |||||||||
| NPI: | 1053958546 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THACKER | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | WHNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6626 E 75TH ST STE 500 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462502890 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1130 MEDICAL ARTS BLVD STE 250 | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460113431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652984282 | ||||||||
| FaxNumber: | 7652984989 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2019 | ||||||||
| LastUpdateDate: | 09/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LW0102X | 28150756A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
ID Information
| ID | Type | State | Issuer | Description | 300035751 | 05 | IN | MEDICAID |