Provider Demographics
NPI:1295455335
Name:SPACH, JONATHAN W (SCAT, ATC)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:W
Last Name:SPACH
Suffix:
Gender:M
Credentials:SCAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 GERVAIS ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1803
Mailing Address - Country:US
Mailing Address - Phone:704-421-0395
Mailing Address - Fax:
Practice Address - Street 1:921 ASSEMBLY ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29208-8686
Practice Address - Country:US
Practice Address - Phone:803-777-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2023-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program