Provider Demographics
NPI:1083144349
Name:PARKS, JADORA BREAL
Entity Type:Individual
Prefix:MISS
First Name:JADORA
Middle Name:BREAL
Last Name:PARKS
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 1:1603 AVERY LN
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-4189
Mailing Address - Country:US
Mailing Address - Phone:502-296-6734
Mailing Address - Fax:
Practice Address - Street 1:1302 WALL ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3885
Practice Address - Country:US
Practice Address - Phone:812-288-4304
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2022-08-24
Deactivation Date:2022-06-17
Deactivation Code:
Reactivation Date:2022-08-24
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician