Healthcare Provider Details

I. General information

NPI: 1104210194
Provider Name (Legal Business Name): JHAELYN ALENZIA ODOM N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2015
Last Update Date: 07/15/2024
Certification Date: 07/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2891 LAKEWOOD AVE SW
ATLANTA GA
30315-5803
US

IV. Provider business mailing address

5925 SAN JUAN DR
BATON ROUGE LA
70811-4128
US

V. Phone/Fax

Practice location:
  • Phone: 678-927-9996
  • Fax: 678-390-9775
Mailing address:
  • Phone: 225-931-2594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN221177
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN133392
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95002527
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAP08578
License Number StateLA
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN95062945
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: