Provider Demographics
NPI:1932972247
Name:PRO HEALTH PSYCHIATRY NURSING CORPORATION
Entity type:Organization
Organization Name:PRO HEALTH PSYCHIATRY NURSING CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:OLSEN
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP
Authorized Official - Phone:562-833-0518
Mailing Address - Street 1:4533 MACARTHUR BLVD STE A-2068
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2059
Mailing Address - Country:US
Mailing Address - Phone:562-833-0518
Mailing Address - Fax:
Practice Address - Street 1:4533 MACARTHUR BLVD STE A-2068
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2059
Practice Address - Country:US
Practice Address - Phone:562-833-0518
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-30
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty