Healthcare Provider Details

I. General information

NPI: 1285623439
Provider Name (Legal Business Name): JENNIFER LEA OLSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 02/15/2021
Certification Date: 02/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

922 22ND AVE S
BROOKINGS SD
57006-2830
US

IV. Provider business mailing address

922 22ND AVE S
BROOKINGS SD
57006-2830
US

V. Phone/Fax

Practice location:
  • Phone: 605-697-1900
  • Fax: 605-697-1919
Mailing address:
  • Phone: 605-697-1900
  • Fax: 605-697-1919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5937
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5215
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: