Provider Demographics
NPI:1912303215
Name:OLSON, JENNIFER (COTA)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:OLSON
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12812 71ST ST APT 618
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8433
Mailing Address - Country:US
Mailing Address - Phone:262-993-6385
Mailing Address - Fax:800-918-8512
Practice Address - Street 1:1615 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60087-3810
Practice Address - Country:US
Practice Address - Phone:847-244-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-13
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL057.004171224Z00000X
FLOTA13956224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1912303215Medicaid