Basic Information
| Provider Information | |||||||||
| NPI: | 1740893288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ODOM | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | ALEXANDER | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ODOM | ||||||||
| OtherFirstName: | JAKE | ||||||||
| OtherMiddleName: | ALEXANDER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 681478 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370681478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6155916590 | ||||||||
| FaxNumber: | 6155916601 | ||||||||
| Practice Location | |||||||||
| Address1: | 119 SEABOARD LN STE 408 | ||||||||
| Address2: | |||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370678307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157789894 | ||||||||
| FaxNumber: | 6157789843 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2020 | ||||||||
| LastUpdateDate: | 06/03/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12853 | TN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 044631 | 05 | TN | MEDICAID |