Provider Demographics
NPI:1649077231
Name:ODEN, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:ODEN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:731 S PLYMOUTH CT APT 608
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60605-2236
Mailing Address - Country:US
Mailing Address - Phone:580-481-0386
Mailing Address - Fax:
Practice Address - Street 1:731 S PLYMOUTH CT
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-2097
Practice Address - Country:US
Practice Address - Phone:580-481-0386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty