Healthcare Provider Details

I. General information

NPI: 1205247061
Provider Name (Legal Business Name): ODALYS JEANETTE FUENTES LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2014
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date: 12/07/2020
Reactivation Date: 02/24/2021

III. Provider practice location address

1901 CALDWELL BLVD # 1072
NAMPA ID
83651-1506
US

IV. Provider business mailing address

2861 E PINE WOOD DR
NAMPA ID
83687-1000
US

V. Phone/Fax

Practice location:
  • Phone: 626-385-7041
  • Fax: 208-279-0447
Mailing address:
  • Phone: 626-385-7041
  • Fax: 208-279-0447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number95690
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number10277
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT111497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: