Basic Information
| Provider Information | |||||||||
| NPI: | 1881723948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLSGAARD | ||||||||
| FirstName: | JEFF | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MA, MDIV, NCC, LCPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13765 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972130765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712660536 | ||||||||
| FaxNumber: | 8888757309 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 NW CIVIC DR | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | GRESHAM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970303770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036668832 | ||||||||
| FaxNumber: | 5036698641 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 05/27/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 867 - LCPC | MT | N | Behavioral Health & Social Service Providers | Counselor | Professional | 101YP2500X | LPC C3060 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 740233 | 01 | MT | BLUECROSS BLUESHIELD | OTHER | 1881723948 | 01 | NATIONAL PROVIDER IDENTIF | OTHER | 12168943 | 01 | COUNCIL FOR AFFORDABLE QUALITY HEALTHCARE (CAQH) | OTHER | 252790 | 05 | MT | MEDICAID |