Provider Demographics
NPI:1215369764
Name:OLSEN, JERALD RICHARD (DPT)
Entity Type:Individual
Prefix:
First Name:JERALD
Middle Name:RICHARD
Last Name:OLSEN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 N LAKEWOOD DR STE 101
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4928
Mailing Address - Country:US
Mailing Address - Phone:208-667-6264
Mailing Address - Fax:208-664-4313
Practice Address - Street 1:1875 N LAKEWOOD DR STE 101
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4928
Practice Address - Country:US
Practice Address - Phone:208-667-6264
Practice Address - Fax:208-664-4313
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist