Provider Demographics
NPI:1174998371
Name:SPENCER, JEREMY (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:SPENCER
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-1537
Mailing Address - Country:US
Mailing Address - Phone:989-673-6191
Mailing Address - Fax:989-672-2199
Practice Address - Street 1:1525 W CARO RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-9686
Practice Address - Country:US
Practice Address - Phone:989-672-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2024-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704286855363LG0600X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology