Basic Information
| Provider Information | |||||||||
| NPI: | 1649230814 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BODDEN | ||||||||
| FirstName: | JACK | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.H.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847408 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547242111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 UNIVERSITY DR E | ||||||||
| Address2: | |||||||||
| City: | COLLEGE STATION | ||||||||
| State: | TX | ||||||||
| PostalCode: | 778402642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4096913300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 07/10/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 20473 | TX | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 81078P | 01 | TX | BLUE SHIELD | OTHER |