Provider Demographics
NPI:1063291771
Name:OLSEN, JESSICA ARIANE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ARIANE
Last Name:OLSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 JUNIPER CT
Mailing Address - Street 2:
Mailing Address - City:SPRING CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37381-4736
Mailing Address - Country:US
Mailing Address - Phone:240-587-8418
Mailing Address - Fax:
Practice Address - Street 1:7108 S KANNER HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34997-7462
Practice Address - Country:US
Practice Address - Phone:855-832-6727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician