MEDICARE: DR. JERRY GEORGE OLSEN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	J5112	TX

General Provider Information

NPI Number	:	1043301849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY GEORGE OLSEN M.D.

Provider Business Mailing Address
First Line	:	33 LYNN BATTS
Second Line	:	APARTMENT # 3203
City	:	SAN ANTONIO
State	:	TX
Zip	:	78218-3000
Country	:	US
Telephone Number	:	210-820-3225
Fax Number	:	210-567-8414

Provider Business Practice Location Address
First Line	:	6711 S NEW BRAUNFELS AVE
Second Line	:	SUITE 100
City	:	SAN ANTONIO
State	:	TX
Zip	:	78223-3005
Country	:	US
Telephone Number	:	210-531-7716
Fax Number	:	210-531-7478

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/27/2006
Last Update Date	:	07/08/2007

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