Provider Demographics
NPI:1457463788
Name:ODLE, JENNA M (MED, NCC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:ODLE
Suffix:
Gender:F
Credentials:MED, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TRINITY CT
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NM
Mailing Address - Zip Code:87056-9748
Mailing Address - Country:US
Mailing Address - Phone:360-333-2704
Mailing Address - Fax:
Practice Address - Street 1:8920 HOLLY AVE NE STE 102B
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-2989
Practice Address - Country:US
Practice Address - Phone:505-856-6880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health