Provider Demographics
NPI:1245709161
Name:OLSON, JOHN NICHOLAS
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:NICHOLAS
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 1:1001 ALCAZAR ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7103
Mailing Address - Country:US
Mailing Address - Phone:904-404-6026
Mailing Address - Fax:
Practice Address - Street 1:6800 FRANKLIN NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-7647
Practice Address - Country:US
Practice Address - Phone:505-338-2526
Practice Address - Fax:505-771-0956
Is Sole Proprietor?:No
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMM-105361041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool