Provider Demographics
NPI:1922467414
Name:ODUSELU, JACQUELINE (MS, NCC, LPC, CPCS)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:ODUSELU
Suffix:
Gender:F
Credentials:MS, NCC, LPC, CPCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2656
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-0012
Mailing Address - Country:US
Mailing Address - Phone:404-644-5523
Mailing Address - Fax:
Practice Address - Street 1:1827 BRACKENDALE RD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-7747
Practice Address - Country:US
Practice Address - Phone:678-582-1469
Practice Address - Fax:770-212-2210
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC008829101Y00000X, 101YM0800X, 101YP1600X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral