Provider Demographics
NPI:1053958546
Name:BODE, JESSICA D
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:D
Last Name:BODE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:THACKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHNP
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1130 MEDICAL ARTS BLVD STE 250
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46011-3431
Practice Address - Country:US
Practice Address - Phone:765-298-4282
Practice Address - Fax:765-298-4989
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28150756A363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300035751Medicaid