Healthcare Provider Details

I. General information

NPI: 1003273772
Provider Name (Legal Business Name): JESSICA ODDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2016
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SHADY OAKS DR
COVINGTON LA
70433-6824
US

IV. Provider business mailing address

31 SHADY OAKS DR
COVINGTON LA
70433-6824
US

V. Phone/Fax

Practice location:
  • Phone: 504-224-0288
  • Fax:
Mailing address:
  • Phone: 504-224-0288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5040
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: