Basic Information
| Provider Information | |||||||||
| NPI: | 1649625880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODOM | ||||||||
| FirstName: | JESS | ||||||||
| MiddleName: | ERIK | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 839 9TH ST STE F | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076338026 | ||||||||
| FaxNumber: | 7074433204 | ||||||||
| Practice Location | |||||||||
| Address1: | 839 9TH ST STE F | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7076338026 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2016 | ||||||||
| LastUpdateDate: | 09/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT88584 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.