Basic Information
| Provider Information | |||||||||
| NPI: | 1023677036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLDS | ||||||||
| FirstName: | JAILENE | ||||||||
| MiddleName: | ERICKA | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1319 MAYFIELD RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | MAYFIELD HTS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441241538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2164799608 | ||||||||
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| Practice Location | |||||||||
| Address1: | 163 STORMONT ST | ||||||||
| Address2: | |||||||||
| City: | NEW CONCORD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437621118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7408268211 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2019 | ||||||||
| LastUpdateDate: | 06/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT005931 | OH | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.