Provider Demographics
NPI:1952031130
Name:SPREEN, JACK ROBERT (PA)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:ROBERT
Last Name:SPREEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-423-8780
Mailing Address - Fax:310-423-0424
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-8780
Practice Address - Fax:310-423-0424
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-12
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA61755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant