Healthcare Provider Details

I. General information

NPI: 1932869914
Provider Name (Legal Business Name): JONATHAN OLVERA MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2021
Last Update Date: 12/18/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 ABRAMS RD
RICHARDSON TX
75081-5578
US

IV. Provider business mailing address

1027 ARBORSIDE DR
MESQUITE TX
75150-6012
US

V. Phone/Fax

Practice location:
  • Phone: 469-619-7622
  • Fax:
Mailing address:
  • Phone: 469-275-3624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number87542
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: