Provider Demographics
NPI:1750800579
Name:OLIVAS, JACOB JEREMIAH
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JEREMIAH
Last Name:OLIVAS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 14TH ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-3815
Mailing Address - Country:US
Mailing Address - Phone:951-955-1540
Mailing Address - Fax:
Practice Address - Street 1:1405 SPRUCE ST
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2410
Practice Address - Country:US
Practice Address - Phone:951-715-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-13
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health