Provider Demographics
NPI:1700995354
Name:SPENCER, JASON CHAUNCEY (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:CHAUNCEY
Last Name:SPENCER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 YACHTSMEN COURT
Mailing Address - Street 2:
Mailing Address - City:WOODBINE
Mailing Address - State:GA
Mailing Address - Zip Code:31569
Mailing Address - Country:US
Mailing Address - Phone:912-541-0243
Mailing Address - Fax:
Practice Address - Street 1:8761 PERIMETER PARK BLVD STE 106
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6397
Practice Address - Country:US
Practice Address - Phone:904-621-6628
Practice Address - Fax:904-346-0113
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003768363A00000X
FLPA9103004363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002298FMedicaid
GA100002298DMedicaid
GA10059208OtherAMERIGROUP
GA10059208OtherAMERIGROUP
GA97WCGVHMedicare ID - Type Unspecified
GA100002298FMedicaid
FLU6552ZMedicare ID - Type Unspecified
GA97WCFGCMedicare PIN