Healthcare Provider Details

I. General information

NPI: 1538988464
Provider Name (Legal Business Name): JENNIFER OLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 UNITED WAY
FREDERIC WI
54837-8938
US

IV. Provider business mailing address

PO BOX 309
SIREN WI
54872-0309
US

V. Phone/Fax

Practice location:
  • Phone: 715-327-4402
  • Fax:
Mailing address:
  • Phone: 715-327-7112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number5234
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: