Provider Demographics
NPI:1336658913
Name:SPARGUR, JESSICA SHANNON (M A)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SHANNON
Last Name:SPARGUR
Suffix:
Gender:F
Credentials:M A
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 4401
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92605-4401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5 MAREBLU
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-3014
Practice Address - Country:US
Practice Address - Phone:949-643-6901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-26
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117409106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU6686052801OtherCIGNA