Provider Demographics
NPI:1730269770
Name:OLSON, JENNIFER LYNN (MD)
Entity type:Individual
Prefix:MISS
First Name:JENNIFER
Middle Name:LYNN
Last Name:OLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 W WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32750-4038
Mailing Address - Country:US
Mailing Address - Phone:407-262-2220
Mailing Address - Fax:407-834-5011
Practice Address - Street 1:455 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4038
Practice Address - Country:US
Practice Address - Phone:407-262-2220
Practice Address - Fax:407-834-5011
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000436192084P0800X
FLME1427722084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL118642600Medicaid
WA8405557Medicaid
WA6889OLOtherREGENCE INS ID NUM