Provider Demographics
NPI:1003195793
Name:SPARKS, JACQUELINE DENISE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:DENISE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12552 CANYON HILL DR
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77318-5742
Mailing Address - Country:US
Mailing Address - Phone:936-445-9141
Mailing Address - Fax:
Practice Address - Street 1:12552 CANYON HILL DR
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77318-4641
Practice Address - Country:US
Practice Address - Phone:936-445-9141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health