Provider Demographics
NPI:1922097997
Name:ODELL, JACQUELINE ANN (PT)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:ODELL
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9612 270TH ST NW
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292-1906
Mailing Address - Country:US
Mailing Address - Phone:360-629-8043
Mailing Address - Fax:360-629-8053
Practice Address - Street 1:9612 270TH ST NW
Practice Address - Street 2:
Practice Address - City:STANWOOD
Practice Address - State:WA
Practice Address - Zip Code:98292-1906
Practice Address - Country:US
Practice Address - Phone:360-629-8043
Practice Address - Fax:360-629-8053
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00002424225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7035843Medicaid
WAGAB08627Medicare PIN
WAS76918Medicare UPIN