Provider Demographics
NPI:1063034916
Name:ODOM, MCKENZIE JEAN
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:JEAN
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 OLD 49 HWY
Mailing Address - Street 2:
Mailing Address - City:ERIN
Mailing Address - State:TN
Mailing Address - Zip Code:37061-4847
Mailing Address - Country:US
Mailing Address - Phone:931-436-5363
Mailing Address - Fax:
Practice Address - Street 1:1620 OLD 49 HWY
Practice Address - Street 2:
Practice Address - City:ERIN
Practice Address - State:TN
Practice Address - Zip Code:37061-4847
Practice Address - Country:US
Practice Address - Phone:931-436-5363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-14
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor