Provider Demographics
NPI:1104063056
Name:SPARKS, JEANINE B (LPC)
Entity type:Individual
Prefix:
First Name:JEANINE
Middle Name:B
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:491 N KNIK ST
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7049
Mailing Address - Country:US
Mailing Address - Phone:907-727-8103
Mailing Address - Fax:
Practice Address - Street 1:491 N KNIK ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7049
Practice Address - Country:US
Practice Address - Phone:907-727-8103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-14
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK512101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional