Provider Demographics
NPI:1902789795
Name:ODERMANN, KYLA JO
Entity type:Individual
Prefix:
First Name:KYLA
Middle Name:JO
Last Name:ODERMANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KYLA
Other - Middle Name:JO
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2142 E C ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-2405
Mailing Address - Country:US
Mailing Address - Phone:406-366-3336
Mailing Address - Fax:
Practice Address - Street 1:1649 61ST STREET, ST 301, 3RD FL, BROOKLYN, NY 11204-33
Practice Address - Street 2:1649 61ST STREET, ST 301, 3RD FL
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-3319
Practice Address - Country:US
Practice Address - Phone:406-366-3336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-29
Last Update Date:2025-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician