Basic Information
| Provider Information | |||||||||
| NPI: | 1669681599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SPEARS | ||||||||
| FirstName: | JIMMY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CDCI | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 71023 | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997071023 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1027 EVERGREEN ST | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997094306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074518164 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3245S0500X | 3323 | AK | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | Substance Abuse Treatment, Children |
No ID Information.