Provider Demographics
NPI:1093467938
Name:SPANN, JAY ADOLPHUS
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:ADOLPHUS
Last Name:SPANN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4233 E ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63115-3304
Mailing Address - Country:US
Mailing Address - Phone:314-917-8491
Mailing Address - Fax:
Practice Address - Street 1:4233 E ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63115-3304
Practice Address - Country:US
Practice Address - Phone:314-917-8491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant