Provider Demographics
NPI:1801580626
Name:ODOM, JAUNICE
Entity type:Individual
Prefix:
First Name:JAUNICE
Middle Name:
Last Name:ODOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 MASSACHUSETTS AVE SE BLDG 13
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-2542
Mailing Address - Country:US
Mailing Address - Phone:202-603-3405
Mailing Address - Fax:
Practice Address - Street 1:1900 MASSACHUSETTS AVE SE BLDG 13
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-2542
Practice Address - Country:US
Practice Address - Phone:202-603-3405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN1003726164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse