Provider Demographics
NPI:1235743006
Name:ODETTE, JACQUELINE (DTR, CDM, CFPP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:ODETTE
Suffix:
Gender:F
Credentials:DTR, CDM, CFPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1285 CLEAVER RD
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-9241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2328 N THOMAS RD
Practice Address - Street 2:
Practice Address - City:FAIRGROVE
Practice Address - State:MI
Practice Address - Zip Code:48733-9569
Practice Address - Country:US
Practice Address - Phone:989-233-2373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI86198282136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered