Provider Demographics
NPI:1740893288
Name:ODOM, JACOB ALEXANDER (PT, DPT)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:ALEXANDER
Last Name:ODOM
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:JAKE
Other - Middle Name:ALEXANDER
Other - Last Name:ODOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT, DPT
Mailing Address - Street 1:PO BOX 681478
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37068-1478
Mailing Address - Country:US
Mailing Address - Phone:615-591-6590
Mailing Address - Fax:615-591-6601
Practice Address - Street 1:119 SEABOARD LN STE 408
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-8307
Practice Address - Country:US
Practice Address - Phone:615-778-9894
Practice Address - Fax:615-778-9843
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12853225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN044631Medicaid