Provider Demographics
NPI:1386914638
Name:SPARKS, JORDAN NICOLE (COTA)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:NICOLE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 130189
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75713-0189
Mailing Address - Country:US
Mailing Address - Phone:903-939-7500
Mailing Address - Fax:903-939-7754
Practice Address - Street 1:3414 GOLDEN RD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-8336
Practice Address - Country:US
Practice Address - Phone:903-939-7500
Practice Address - Fax:903-939-7754
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210115224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant