Provider Demographics
NPI:1881841476
Name:ODUM, KELLY K (LCSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:ODUM
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2337
Mailing Address - Country:US
Mailing Address - Phone:731-664-2083
Mailing Address - Fax:731-664-1988
Practice Address - Street 1:45 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2337
Practice Address - Country:US
Practice Address - Phone:731-664-2083
Practice Address - Fax:731-664-1988
Is Sole Proprietor?:No
Enumeration Date:2008-08-26
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLCSW34311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical