Healthcare Provider Details

I. General information

NPI: 1871414516
Provider Name (Legal Business Name): KAELYN ODOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 E HIGHLAND DR
JONESBORO AR
72401-6231
US

IV. Provider business mailing address

4800 RESERVE BLVD APT M5
JONESBORO AR
72405-7279
US

V. Phone/Fax

Practice location:
  • Phone: 870-701-5089
  • Fax: 870-277-0896
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA5123
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: