Healthcare Provider Details

I. General information

NPI: 1255465720
Provider Name (Legal Business Name): JESSICA SPAYD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2007
Last Update Date: 04/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11823 OLD GLENN HWY SUITE 110
EAGLE RIVER AK
99577-7734
US

IV. Provider business mailing address

11823 OLD GLENN HWY SUITE 110
EAGLE RIVER AK
99577-7734
US

V. Phone/Fax

Practice location:
  • Phone: 907-622-4673
  • Fax: 907-622-4674
Mailing address:
  • Phone: 907-622-4673
  • Fax: 907-622-4674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4245, 677, 20608
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number4245, 677, 20608
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number4245, 677, 20608
License Number StateAK
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4245, 677, 20608
License Number StateAK
# 5
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number4245, 677, 20608
License Number StateAK
# 6
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4245, 677, 20608
License Number StateAK
# 7
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number4245, 677, 20608
License Number StateAK

VIII. Authorized Official

Name: JESSICA J SPAYD
Title or Position: REGISTERED AGENT
Credential: ANP
Phone: 907-622-4673