Provider Demographics
NPI:1023677036
Name:OLDS, JAILENE ERICKA (ATC)
Entity type:Individual
Prefix:
First Name:JAILENE
Middle Name:ERICKA
Last Name:OLDS
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1319 MAYFIELD RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44124-1538
Mailing Address - Country:US
Mailing Address - Phone:216-479-9608
Mailing Address - Fax:
Practice Address - Street 1:163 STORMONT ST
Practice Address - Street 2:
Practice Address - City:NEW CONCORD
Practice Address - State:OH
Practice Address - Zip Code:43762-1118
Practice Address - Country:US
Practice Address - Phone:740-826-8211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-12
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT0059312255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Multi-Specialty