Provider Demographics
NPI:1922582873
Name:OLSON, JACOB B
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:B
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 1:105 S WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-4667
Mailing Address - Country:US
Mailing Address - Phone:931-526-9518
Mailing Address - Fax:931-372-0087
Practice Address - Street 1:105 S WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-4667
Practice Address - Country:US
Practice Address - Phone:931-526-9518
Practice Address - Fax:931-372-0087
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA03726207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ047209Medicaid