Healthcare Provider Details

I. General information

NPI: 1447210257
Provider Name (Legal Business Name): JEFFREY THOMAS SPENCER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 BELFORT RD
JACKSONVILLE FL
32256-6004
US

IV. Provider business mailing address

86648 RIVERWOOD DR
YULEE FL
32097-6446
US

V. Phone/Fax

Practice location:
  • Phone: 904-483-5850
  • Fax: 904-265-6409
Mailing address:
  • Phone: 904-307-5981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9173128
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN231221
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: