Basic Information
| Provider Information | |||||||||
| NPI: | 1487925194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODENBACH | ||||||||
| FirstName: | JAYNE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4750 E GALBRAITH RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452366706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134213494 | ||||||||
| FaxNumber: | 5133452606 | ||||||||
| Practice Location | |||||||||
| Address1: | 4750 E GALBRAITH RD STE 125 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452366706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134213494 | ||||||||
| FaxNumber: | 5133452606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2012 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3007296 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | APRN.CNP.15823 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 7100201450 | 05 | KY | MEDICAID | 0060635 | 05 | OH | MEDICAID |