Healthcare Provider Details

I. General information

NPI: 1922467414
Provider Name (Legal Business Name): JACQUELINE ODUSELU MS, NCC, LPC, CPCS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2016
Last Update Date: 06/22/2024
Certification Date: 06/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827 BRACKENDALE RD NW
KENNESAW GA
30152-7747
US

IV. Provider business mailing address

1827 BRACKENDALE RD NW
KENNESAW GA
30152-7747
US

V. Phone/Fax

Practice location:
  • Phone: 678-582-1469
  • Fax: 770-212-2210
Mailing address:
  • Phone: 678-582-1469
  • Fax: 770-212-2210

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLPC008829
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC008829
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License NumberLPC008829
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC008829
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: