Provider Demographics
NPI:1861547143
Name:OLSON, JEFFREY RAY (LAC)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:RAY
Last Name:OLSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 E MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-3848
Mailing Address - Country:US
Mailing Address - Phone:701-426-6308
Mailing Address - Fax:
Practice Address - Street 1:208 E MAIN AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-3848
Practice Address - Country:US
Practice Address - Phone:701-426-6308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1093101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND27175OtherBCSND PROVIDER NUMBER