MEDICARE: DR. JONATHAN SPEARE PHD LICENSED PSYCHOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP0655	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	074048	OTHER	MN	VALUE OPTIONS
2	100318	OTHER	MN	PREFERRED ONE
3	110500	OTHER	MN	UCARE
4	8L597SP	OTHER	MN	BCBS
5	000512001	OTHER	MN	MAGELLAN
6	6101470	OTHER	MN	UNITED BEHAVIORAL HEALTH
7	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962537282
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JONATHAN SPEARE PHD LICENSED PSYCHOL

Provider Business Mailing Address
First Line	:	225 1ST ST N
Second Line	:	SUITE 3100
City	:	VIRGINIA
State	:	MN
Zip	:	55792-2457
Country	:	US
Telephone Number	:	218-741-3740
Fax Number	:

Provider Business Practice Location Address
First Line	:	225 1ST ST N
Second Line	:	SUITE 3100
City	:	VIRGINIA
State	:	MN
Zip	:	55792-2457
Country	:	US
Telephone Number	:	218-741-3740
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	08/10/2010

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Directions to “ DR. JONATHAN SPEARE PHD LICENSED PSYCHOL” Practice Location

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