Provider Demographics
NPI:1689004350
Name:SPAETH, JESSICA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:
Last Name:SPAETH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2601 IRON GATE DR STE 101
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6624
Mailing Address - Country:US
Mailing Address - Phone:910-202-9113
Mailing Address - Fax:
Practice Address - Street 1:2601 IRON GATE DR STE 101
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-6624
Practice Address - Country:US
Practice Address - Phone:910-202-9113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-18
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4542103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist