Provider Demographics
NPI:1568210938
Name:OLSEN, JACE AXEL
Entity type:Individual
Prefix:
First Name:JACE
Middle Name:AXEL
Last Name:OLSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 879388
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-9388
Mailing Address - Country:US
Mailing Address - Phone:907-903-7779
Mailing Address - Fax:
Practice Address - Street 1:7610 E PALMER WASILLA HWY
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-8467
Practice Address - Country:US
Practice Address - Phone:907-903-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst