Provider Demographics
NPI:1801108345
Name:ODOM, LISA NICHOLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:NICHOLE
Last Name:ODOM
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:NICHOLE
Other - Last Name:JACOBSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:2120 ALPINE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:CA
Mailing Address - Zip Code:91901-2113
Mailing Address - Country:US
Mailing Address - Phone:619-544-0633
Mailing Address - Fax:
Practice Address - Street 1:2120 ALPINE BLVD.
Practice Address - Street 2:2120 ALPINE BOULEVARD
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901
Practice Address - Country:US
Practice Address - Phone:619-544-0633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health