Provider Demographics
NPI:1952455800
Name:OLSON, JEREMIAH LEE (CSAC, ICS)
Entity Type:Individual
Prefix:MR
First Name:JEREMIAH
Middle Name:LEE
Last Name:OLSON
Suffix:
Gender:M
Credentials:CSAC, ICS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 SOUTH DRIVE
Mailing Address - Street 2:
Mailing Address - City:WINNEBAGO
Mailing Address - State:WI
Mailing Address - Zip Code:54985-0009
Mailing Address - Country:US
Mailing Address - Phone:920-235-4910
Mailing Address - Fax:920-237-2043
Practice Address - Street 1:1300 SOUTH DRIVE
Practice Address - Street 2:
Practice Address - City:WINNEBAGO
Practice Address - State:WI
Practice Address - Zip Code:54985-0009
Practice Address - Country:US
Practice Address - Phone:920-235-4910
Practice Address - Fax:920-237-2043
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI11698101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39171000Medicaid