Healthcare Provider Details

I. General information

NPI: 1487740502
Provider Name (Legal Business Name): JONATHAN WILLIAM SPENCE P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 BATTLEFIELD BLVD N
CHESAPEAKE VA
23320-4901
US

IV. Provider business mailing address

1 U S COAST GUARD TRN CTR
YORKTOWN VA
23690-5001
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-0688
  • Fax:
Mailing address:
  • Phone: 757-856-2565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110003960
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: