Basic Information
| Provider Information | |||||||||
| NPI: | 1619278645 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODLE | ||||||||
| FirstName: | JACQLN | ||||||||
| MiddleName: | KENDRA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 760 BROADWAY RM 5A-206 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112065317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638713 | ||||||||
| FaxNumber: | 7186303138 | ||||||||
| Practice Location | |||||||||
| Address1: | 760 BROADWAY | ||||||||
| Address2: | WOODHULL HOSPITAL | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112065317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189638713 | ||||||||
| FaxNumber: | 7186303138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2010 | ||||||||
| LastUpdateDate: | 11/08/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 079620 | NY | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.