Provider Demographics
NPI:1164014627
Name:ODNERT, JEFFREY ALAN (DACM, L AC)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:ALAN
Last Name:ODNERT
Suffix:
Gender:M
Credentials:DACM, L AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 HORNBLEND ST STE C
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-4057
Mailing Address - Country:US
Mailing Address - Phone:619-738-3035
Mailing Address - Fax:
Practice Address - Street 1:945 HORNBLEND ST STE C
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-4057
Practice Address - Country:US
Practice Address - Phone:619-738-3035
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-05
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18990171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18990OtherCALIFORNIA ACUPUNCTURE LICENSE