MEDICARE: AMY J OLSON R.D., C.D.E.

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	133V00000X	Registered Dietitian	164001786	IL
2	133V00000X	Registered Dietitian	D1282	MS

General Provider Information

NPI Number	:	1659369494
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMY J OLSON R.D., C.D.E.

Provider Business Mailing Address
First Line	:	1040 RIVER OAKS DR
Second Line	:	SUITE 302
City	:	JACKSON
State	:	MS
Zip	:	39232-9530
Country	:	US
Telephone Number	:	601-939-9923
Fax Number	:

Provider Business Practice Location Address
First Line	:	1040 RIVER OAKS DR
Second Line	:	SUITE 302
City	:	JACKSON
State	:	MS
Zip	:	39232-9530
Country	:	US
Telephone Number	:	601-939-9923
Fax Number	:

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

Provider Enumeration Date	:	10/06/2005
Last Update Date	:	03/07/2014

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