Basic Information
| Provider Information | |||||||||
| NPI: | 1275678138 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODDEN | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | |||||||||
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| OtherOrganizationType: | |||||||||
| OtherLastName: | BODDEN | ||||||||
| OtherFirstName: | JANE | ||||||||
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| OtherCredential: | NP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 173891 | ||||||||
| Address2: | |||||||||
| City: | DENVER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 802179294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3033067783 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E BOULDER ST | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809095533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193656820 | ||||||||
| FaxNumber: | 3033067753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 07/26/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 96228 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 25088572 | 05 | CO | MEDICAID |