Provider Demographics
NPI:1679537872
Name:OLSON, JEFF (LAC, MACOM)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:OLSON
Suffix:
Gender:M
Credentials:LAC, MACOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1436 A ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-2378
Mailing Address - Country:US
Mailing Address - Phone:360-207-0134
Mailing Address - Fax:
Practice Address - Street 1:1436 A ST
Practice Address - Street 2:SUITE 105
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-2378
Practice Address - Country:US
Practice Address - Phone:360-207-0134
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00901171100000X
WAAC 60619873171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist