Provider Demographics
NPI:1467705400
Name:OLSON, JACOB JOSEPH (PHARM D)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:JOSEPH
Last Name:OLSON
Suffix:
Gender:M
Credentials:PHARM D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W170N5353 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-0676
Mailing Address - Country:US
Mailing Address - Phone:414-881-1317
Mailing Address - Fax:
Practice Address - Street 1:9000 W WISCONSIN AVE
Practice Address - Street 2:CHILDREN'S CLINICS BLDG
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-4874
Practice Address - Country:US
Practice Address - Phone:414-266-1893
Practice Address - Fax:414-266-1894
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-15
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26020025A183500000X
WI13224-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist