Basic Information
| Provider Information | |||||||||
| NPI: | 1306838669 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4567 CROSSROADS PARK DR. | ||||||||
| Address2: | |||||||||
| City: | LIVERPOOL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 13088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152952100 | ||||||||
| FaxNumber: | 3152952125 | ||||||||
| Practice Location | |||||||||
| Address1: | 1452 DEER PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NORTH BABYLON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312548500 | ||||||||
| FaxNumber: | 6312548503 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2005 | ||||||||
| LastUpdateDate: | 03/09/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 214310 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02109855 | 05 | NY | MEDICAID |