Healthcare Provider Details

I. General information

NPI: 1093635120
Provider Name (Legal Business Name): ALYSSA JANE OLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALYSSA OLSON

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10615 SE CHERRY BLOSSOM DR STE 250
PORTLAND OR
97216-3137
US

IV. Provider business mailing address

10615 SE CHERRY BLOSSOM DR STE 250
PORTLAND OR
97216-3137
US

V. Phone/Fax

Practice location:
  • Phone: 971-373-4085
  • Fax:
Mailing address:
  • Phone: 971-373-4085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: