Provider Demographics
NPI:1073202834
Name:OLSEN, JANZSEN EPHRAIM
Entity Type:Individual
Prefix:
First Name:JANZSEN
Middle Name:EPHRAIM
Last Name:OLSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20130
Mailing Address - Street 2:UNIT 55984
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:83303-5949
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:859 S YELLOWSTONE HWY STE 202
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5294
Practice Address - Country:US
Practice Address - Phone:307-257-5487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician