Provider Demographics
NPI:1104210194
Name:ODOM, JHAELYN ALENZIA (NP)
Entity Type:Individual
Prefix:
First Name:JHAELYN
Middle Name:ALENZIA
Last Name:ODOM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 SAN JUAN DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70811-4128
Mailing Address - Country:US
Mailing Address - Phone:225-931-2594
Mailing Address - Fax:
Practice Address - Street 1:5925 SAN JUAN DR
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70811-4128
Practice Address - Country:US
Practice Address - Phone:225-931-2594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-27
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN95062945163W00000X
LARN133392163W00000X
CA95002527363L00000X
GARN221177363LW0102X
LAAP08578363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner