Provider Demographics
NPI:1386484566
Name:ODLE, JALEN MICHELLE (COTA/L)
Entity type:Individual
Prefix:
First Name:JALEN
Middle Name:MICHELLE
Last Name:ODLE
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 SUNSET TRL
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-2365
Mailing Address - Country:US
Mailing Address - Phone:210-501-8705
Mailing Address - Fax:
Practice Address - Street 1:5000 HIGHWAY 17 BYP S
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-4500
Practice Address - Country:US
Practice Address - Phone:843-252-0033
Practice Address - Fax:843-582-0259
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5665224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant