Healthcare Provider Details

I. General information

NPI: 1073859260
Provider Name (Legal Business Name): JESSICA OLLMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2012
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W MAIN ST
PORT WASHINGTON WI
53074-1813
US

IV. Provider business mailing address

121 W MAIN ST
PORT WASHINGTON WI
53074-1813
US

V. Phone/Fax

Practice location:
  • Phone: 262-284-8148
  • Fax: 262-284-8209
Mailing address:
  • Phone: 262-284-8148
  • Fax: 262-284-8209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1257-226
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number1257-226
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: