Provider Demographics
NPI:1962537282
Name:SPEARE, JONATHAN (PHD LICENSED PSYCHOL)
Entity type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:
Last Name:SPEARE
Suffix:
Gender:M
Credentials:PHD LICENSED PSYCHOL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 1ST ST N
Mailing Address - Street 2:SUITE 3100
Mailing Address - City:VIRGINIA
Mailing Address - State:MN
Mailing Address - Zip Code:55792-2457
Mailing Address - Country:US
Mailing Address - Phone:218-741-3740
Mailing Address - Fax:
Practice Address - Street 1:225 1ST ST N
Practice Address - Street 2:SUITE 3100
Practice Address - City:VIRGINIA
Practice Address - State:MN
Practice Address - Zip Code:55792-2457
Practice Address - Country:US
Practice Address - Phone:218-741-3740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0655103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN074048OtherVALUE OPTIONS
MN100318OtherPREFERRED ONE
MN110500OtherUCARE
MN8L597SPOtherBCBS
MN000512001OtherMAGELLAN
MN6101470OtherUNITED BEHAVIORAL HEALTH
MN850347800Medicaid
MN110500OtherUCARE