Provider Demographics
NPI:1447210257
Name:SPENCER, JEFFREY THOMAS (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:THOMAS
Last Name:SPENCER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86648 RIVERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-6446
Mailing Address - Country:US
Mailing Address - Phone:904-307-5981
Mailing Address - Fax:
Practice Address - Street 1:4800 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-6004
Practice Address - Country:US
Practice Address - Phone:904-483-5850
Practice Address - Fax:904-265-6409
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9173128367500000X
GAAPRN231221367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL306738600Medicaid
GA414335265AMedicaid
FLG3680ZMedicare PIN
FLP00190821Medicare PIN
FLG3680YMedicare PIN