# ODYSSEY FAMILY PRACTICE

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1780142042
- **Authorized official:** JARED LEE WALLACE PA-C (OWNER)
- **Authorized official phone:** (907) 313-4569

## Contact information

- **Practice address:** 11595 KENAI SPUR HIGHWAY, KENAI, AK 99611
- **Practice address phone:** (907) 313-4569
- **Practice address fax:** (907) 313-4939
- **Mailing address:** PO BOX 922, KASILOF, AK 99610-0922

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | — | NULL | Yes |
| 207Q00000X | Family Medicine Physician | — | — | Yes |
| 261QX0100X | Occupational Medicine Clinic/Center | — | NULL | — |
| 291U00000X | Clinical Medical Laboratory | — | NULL | — |

## Other

- **Enumeration date:** 03/06/2019
- **Last updated:** 12/01/2025