Provider Demographics
NPI:1225230519
Name:SPENCER, JAMAAL L (PTA)
Entity Type:Individual
Prefix:MR
First Name:JAMAAL
Middle Name:L
Last Name:SPENCER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7311 LAKE SUZZANNE WAY
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32404-4092
Mailing Address - Country:US
Mailing Address - Phone:334-324-2656
Mailing Address - Fax:
Practice Address - Street 1:3650 MANSELL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-3012
Practice Address - Country:US
Practice Address - Phone:877-896-3660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA 20803225200000X
ALPTA 4763225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant