Healthcare Provider Details

I. General information

NPI: 1144264904
Provider Name (Legal Business Name): JAY EDWARD OLSSON DO PROF ASSOCIATIONN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 09/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 N WICKHAM RD SUITE S
MELBOURNE FL
32935-8659
US

IV. Provider business mailing address

401 N WICKHAM RD SUITE S
MELBOURNE FL
32935-8659
US

V. Phone/Fax

Practice location:
  • Phone: 321-242-9031
  • Fax: 321-242-9035
Mailing address:
  • Phone: 321-242-9031
  • Fax: 321-242-9035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOS0004087
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License NumberOS4087
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: