Provider Demographics
NPI:1992304299
Name:ODEGAARD, JESSALYN RIEDEL (PT, DPT)
Entity type:Individual
Prefix:
First Name:JESSALYN
Middle Name:RIEDEL
Last Name:ODEGAARD
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 STONE ST
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-1428
Mailing Address - Country:US
Mailing Address - Phone:703-727-5534
Mailing Address - Fax:
Practice Address - Street 1:824 GUM BRANCH RD STE W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-6269
Practice Address - Country:US
Practice Address - Phone:252-672-8680
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-19
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP19650225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist