Provider Demographics
NPI:1447430285
Name:ODDI, JACLYN M (DOM)
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:M
Last Name:ODDI
Suffix:
Gender:F
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12131 HWY 14 N
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9461
Mailing Address - Country:US
Mailing Address - Phone:505-269-2599
Mailing Address - Fax:
Practice Address - Street 1:12131 HWY 14 N
Practice Address - Street 2:
Practice Address - City:CEDAR CREST
Practice Address - State:NM
Practice Address - Zip Code:87008-9461
Practice Address - Country:US
Practice Address - Phone:505-269-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM825171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00RH55OtherBCBS