Healthcare Provider Details

I. General information

NPI: 1700995354
Provider Name (Legal Business Name): JASON CHAUNCEY SPENCER PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8761 PERIMETER PARK BLVD STE 106
JACKSONVILLE FL
32216-6397
US

IV. Provider business mailing address

28 YACHTSMEN COURT
WOODBINE GA
31569
US

V. Phone/Fax

Practice location:
  • Phone: 904-621-6628
  • Fax: 904-346-0113
Mailing address:
  • Phone: 912-541-0243
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003768
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9103004
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: