Provider Demographics
NPI:1417318171
Name:OLSON, JONATHAN ALLRED
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ALLRED
Last Name:OLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 CORONADO ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7552
Mailing Address - Country:US
Mailing Address - Phone:208-522-3355
Mailing Address - Fax:208-522-6019
Practice Address - Street 1:2210 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7552
Practice Address - Country:US
Practice Address - Phone:208-522-3355
Practice Address - Fax:208-522-6019
Is Sole Proprietor?:No
Enumeration Date:2016-03-09
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101022655207X00000X
OH58.030544207X00000X
IDPENDING207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery