Basic Information
| Provider Information | |||||||||
| NPI: | 1629206149 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SPENCER | ||||||||
| FirstName: | JESSE | ||||||||
| MiddleName: | NEIL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013875300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 460 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | RICHFIELD | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847011836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4958965496 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2009 | ||||||||
| LastUpdateDate: | 09/18/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4795700-1205 | UT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1629206149 | 05 | UT | MEDICAID |