Provider Demographics
NPI:1457728339
Name:OLSEN, JEANNE E (PA-C)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:E
Last Name:OLSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:E
Other - Last Name:CORBETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7401 104TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-7845
Mailing Address - Country:US
Mailing Address - Phone:262-764-5595
Mailing Address - Fax:262-764-9314
Practice Address - Street 1:7401 104TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-7845
Practice Address - Country:US
Practice Address - Phone:262-764-5595
Practice Address - Fax:262-764-9314
Is Sole Proprietor?:No
Enumeration Date:2015-08-27
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3648-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100047666Medicaid