MEDICARE: JENNIFER OLINE KOLSTAD LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	19693	MN

General Provider Information

NPI Number	:	1336647106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER OLINE KOLSTAD LICSW

Provider Business Mailing Address
First Line	:	100 WARREN ST
Second Line	:	STE 324
City	:	MANKATO
State	:	MN
Zip	:	56001-3762
Country	:	US
Telephone Number	:	507-246-2667
Fax Number	:	507-514-0999

Provider Business Practice Location Address
First Line	:	100 WARREN ST
Second Line	:	STE 324
City	:	MANKATO
State	:	MN
Zip	:	56001-3762
Country	:	US
Telephone Number	:	507-246-2667
Fax Number	:	507-519-0444

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/26/2018
Last Update Date	:	12/30/2021

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