Provider Demographics
NPI:1154989630
Name:ODOR, JARRED
Entity type:Individual
Prefix:
First Name:JARRED
Middle Name:
Last Name:ODOR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 BAYVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:ELIOT
Mailing Address - State:ME
Mailing Address - Zip Code:03903
Mailing Address - Country:US
Mailing Address - Phone:207-608-1901
Mailing Address - Fax:
Practice Address - Street 1:716 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2693
Practice Address - Country:US
Practice Address - Phone:207-221-4516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NH086213-23367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program