Provider Demographics
NPI: | 1548427644 |
---|---|
Name: | SPOON, JOCELYN NICHOLE (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | JOCELYN |
Middle Name: | NICHOLE |
Last Name: | SPOON |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 12 |
Mailing Address - Street 2: | |
Mailing Address - City: | LIBERTY LAKE |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 99019-0012 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 406-327-1918 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 500 W BROADWAY ST |
Practice Address - Street 2: | SUITE 320 |
Practice Address - City: | MISSOULA |
Practice Address - State: | MT |
Practice Address - Zip Code: | 59802-4008 |
Practice Address - Country: | US |
Practice Address - Phone: | 406-329-5615 |
Practice Address - Fax: | 406-329-2791 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-05-18 |
Last Update Date: | 2021-04-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | 104945 | 207RC0000X |
MN | 53479 | 207RC0000X |
IL | 125053081 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RC0000X | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 060003363 | Medicare PIN | |
MT | M011004806 | Medicare PIN |