Provider Demographics
NPI:1922147172
Name:SPENCER, JODIE L
Entity Type:Individual
Prefix:MRS
First Name:JODIE
Middle Name:L
Last Name:SPENCER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 E CALLE DEL RONDADOR
Mailing Address - Street 2:
Mailing Address - City:SAHUARITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85629-8506
Mailing Address - Country:US
Mailing Address - Phone:520-777-3445
Mailing Address - Fax:520-750-9667
Practice Address - Street 1:90 E CALLE DEL RONDADOR
Practice Address - Street 2:
Practice Address - City:SAHUARITA
Practice Address - State:AZ
Practice Address - Zip Code:85629-8506
Practice Address - Country:US
Practice Address - Phone:520-777-3445
Practice Address - Fax:520-750-9667
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12075171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ175641Medicaid