Basic Information
| Provider Information | |||||||||
| NPI: | 1962623595 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'DELL | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | LPCC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 609 BUCK CREEK RD | ||||||||
| Address2: | |||||||||
| City: | SMITHS GROVE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421719284 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 E 2ND ST | ||||||||
| Address2: | SUITE B | ||||||||
| City: | TOMPKINSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421671673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2704875655 | ||||||||
| FaxNumber: | 2704875948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 101YP2500X | 0578 | KY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 30604011 | 05 | KY | MEDICAID |