Provider Demographics
NPI:1649625880
Name:ODOM, JESS ERIK (MFT)
Entity type:Individual
Prefix:MR
First Name:JESS
Middle Name:ERIK
Last Name:ODOM
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:839 9TH ST STE F
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6229
Mailing Address - Country:US
Mailing Address - Phone:707-633-8026
Mailing Address - Fax:707-443-3204
Practice Address - Street 1:839 9TH ST STE F
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-6229
Practice Address - Country:US
Practice Address - Phone:707-633-8026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT88584106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist