Provider Demographics
NPI:1699962324
Name:OLDS, JEFFREY (LICSW)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:OLDS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 S POKEGAMA AVE
Mailing Address - Street 2:STE 160
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-4296
Mailing Address - Country:US
Mailing Address - Phone:218-327-8937
Mailing Address - Fax:218-327-0348
Practice Address - Street 1:35382 US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-4754
Practice Address - Country:US
Practice Address - Phone:218-327-4886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical