Provider Demographics
NPI:1346764180
Name:OLSON, JESSICA LYNN (APNP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:OLSON
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 PENHURST WAY
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53186-1224
Mailing Address - Country:US
Mailing Address - Phone:262-271-6280
Mailing Address - Fax:
Practice Address - Street 1:108 GROVE ST
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:WI
Practice Address - Zip Code:53119-2249
Practice Address - Country:US
Practice Address - Phone:262-544-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-02
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIF08170126207R00000X
WI7942-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100071340Medicaid