Provider Demographics
NPI:1194041061
Name:SPARKS, JENNA L (LMT)
Entity type:Individual
Prefix:MISS
First Name:JENNA
Middle Name:L
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9191 W THUNDERBIRD RD STE 108
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4270
Mailing Address - Country:US
Mailing Address - Phone:623-974-3511
Mailing Address - Fax:623-444-9741
Practice Address - Street 1:9191 W THUNDERBIRD RD STE 108
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4270
Practice Address - Country:US
Practice Address - Phone:623-974-3511
Practice Address - Fax:623-444-9741
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-08278225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist