Healthcare Provider Details

I. General information

NPI: 1265340210
Provider Name (Legal Business Name): JENNIE SPOONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 LEROY ST
POTSDAM NY
13676-1786
US

IV. Provider business mailing address

50 LEROY ST
POTSDAM NY
13676-1786
US

V. Phone/Fax

Practice location:
  • Phone: 315-261-5890
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number360413
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: