Provider Demographics
NPI:1548853633
Name:OLIN, JASON TODD (PHD)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:TODD
Last Name:OLIN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2820 PARK PL
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-2039
Mailing Address - Country:US
Mailing Address - Phone:908-279-3553
Mailing Address - Fax:
Practice Address - Street 1:4100 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1934
Practice Address - Country:US
Practice Address - Phone:949-648-7788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13932103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical