Healthcare Provider Details

I. General information

NPI: 1548195068
Provider Name (Legal Business Name): JENNIFER ODLE SUDRC I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2931 PROSPECT ST
CONCORD CA
94518-1025
US

IV. Provider business mailing address

4858 APPIAN WAY APT 1
EL SOBRANTE CA
94803-1856
US

V. Phone/Fax

Practice location:
  • Phone: 925-676-4840
  • Fax:
Mailing address:
  • Phone: 925-798-7250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number25738
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: