Provider Demographics
NPI:1437419025
Name:JACQUELINE S ODOM PHD
Entity Type:Organization
Organization Name:JACQUELINE S ODOM PHD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:S
Authorized Official - Last Name:ODOM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-202-3367
Mailing Address - Street 1:6250 GILBERT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1926
Mailing Address - Country:US
Mailing Address - Phone:248-202-3367
Mailing Address - Fax:248-254-3333
Practice Address - Street 1:30375 NORTHWESTERN HWY STE 200
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-3299
Practice Address - Country:US
Practice Address - Phone:248-202-3367
Practice Address - Fax:248-254-3333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty