Provider Demographics
NPI:1053362897
Name:KOOP OLSTA, JENNIFER I (PHD)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:I
Last Name:KOOP OLSTA
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:I
Other - Last Name:KOOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:9000 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-955-0660
Mailing Address - Fax:414-955-0076
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-955-0660
Practice Address - Fax:414-955-0076
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2558103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39149800Medicaid
WI1053362897Medicaid
Q56508Medicare UPIN
WI39149800Medicaid