Healthcare Provider Details

I. General information

NPI: 1659814382
Provider Name (Legal Business Name): JENNIFER LYNN OLSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 COOPER FOSTER PARK RD W
LORAIN OH
44053-4152
US

IV. Provider business mailing address

29 HAWTHORNE DR
NORWALK OH
44857-2307
US

V. Phone/Fax

Practice location:
  • Phone: 440-204-7400
  • Fax:
Mailing address:
  • Phone: 567-424-6840
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.020257
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: