Provider Demographics
NPI:1699849992
Name:OLSON, JERRY LYNN (LPC CADC III)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LYNN
Last Name:OLSON
Suffix:
Gender:M
Credentials:LPC CADC III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1703 SAWYER DR
Mailing Address - Street 2:APT. C
Mailing Address - City:MARSHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:54449-1241
Mailing Address - Country:US
Mailing Address - Phone:715-486-1557
Mailing Address - Fax:
Practice Address - Street 1:252 S. CENTRAL AVE. HERGERT AND GAZIANO
Practice Address - Street 2:SUITE # 21
Practice Address - City:MARSHFIELD
Practice Address - State:WI
Practice Address - Zip Code:54449-1241
Practice Address - Country:US
Practice Address - Phone:715-384-7579
Practice Address - Fax:715-384-8131
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
WI1802-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1802-125OtherLPC
WI1063OtherCADC III