Provider Demographics
NPI:1194154005
Name:OLCOTT, JONATHAN ANDREW (LAC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANDREW
Last Name:OLCOTT
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3623
Mailing Address - Country:US
Mailing Address - Phone:805-459-6561
Mailing Address - Fax:
Practice Address - Street 1:1025 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3623
Practice Address - Country:US
Practice Address - Phone:805-459-6561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-01
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15-622171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist