Provider Demographics
NPI:1548078264
Name:SPENCE, JOHNATHAN LEE (PRSS)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:LEE
Last Name:SPENCE
Suffix:
Gender:M
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5198 WHITMAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-8802
Mailing Address - Country:US
Mailing Address - Phone:304-785-2220
Mailing Address - Fax:
Practice Address - Street 1:200 UPPER KANAWHA VALLEY WAY
Practice Address - Street 2:
Practice Address - City:CABIN CREEK
Practice Address - State:WV
Practice Address - Zip Code:25035
Practice Address - Country:US
Practice Address - Phone:681-265-5090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)