Provider Demographics
NPI:1497095129
Name:OLSON, JEFFERSON OREN (PTA)
Entity Type:Individual
Prefix:MR
First Name:JEFFERSON
Middle Name:OREN
Last Name:OLSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2229 W TANQUE VERDE DR
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85224-8371
Mailing Address - Country:US
Mailing Address - Phone:602-616-0266
Mailing Address - Fax:
Practice Address - Street 1:2229 W TANQUE VERDE DR
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-8371
Practice Address - Country:US
Practice Address - Phone:602-616-0266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-16
Last Update Date:2013-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7494A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant