Provider Demographics
NPI:1962054742
Name:ODELL, JESSE JONATHAN (DC)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:JONATHAN
Last Name:ODELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-2412
Mailing Address - Country:US
Mailing Address - Phone:716-322-0290
Mailing Address - Fax:716-322-0361
Practice Address - Street 1:295 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-2412
Practice Address - Country:US
Practice Address - Phone:716-322-0290
Practice Address - Fax:716-322-0361
Is Sole Proprietor?:No
Enumeration Date:2019-07-12
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX013265-01111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor