Provider Demographics
NPI:1407096027
Name:SPARKS, JASON PHILIP (MED, CPHT, PHTR)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:PHILIP
Last Name:SPARKS
Suffix:
Gender:M
Credentials:MED, CPHT, PHTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11970 JOLLYVILLE RD # 215
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-2329
Mailing Address - Country:US
Mailing Address - Phone:512-983-1740
Mailing Address - Fax:
Practice Address - Street 1:11113 RESEARCH BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-5236
Practice Address - Country:US
Practice Address - Phone:512-324-6395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-22
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100125183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician