Provider Demographics
NPI:1619588506
Name:ODOM, JEAN MARIE
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:MARIE
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 SOUTHWESTERN BLVD STE 105
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3767
Mailing Address - Country:US
Mailing Address - Phone:281-903-5353
Mailing Address - Fax:
Practice Address - Street 1:101 SOUTHWESTERN BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3767
Practice Address - Country:US
Practice Address - Phone:281-903-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX78280101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health