Provider Demographics
NPI:1881795276
Name:OLSON, JEFFREY L (PSYD LP)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:OLSON
Suffix:
Gender:M
Credentials:PSYD LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4891 MILLER TRUNK HWY
Mailing Address - Street 2:SUITE 106
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-1512
Mailing Address - Country:US
Mailing Address - Phone:218-722-2525
Mailing Address - Fax:218-722-1033
Practice Address - Street 1:4891 MILLER TRUNK HWY
Practice Address - Street 2:SUITE 106
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-1512
Practice Address - Country:US
Practice Address - Phone:218-722-2525
Practice Address - Fax:218-722-1033
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP4532103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN572408200Medicaid
MN680001936Medicare ID - Type Unspecified