Provider Demographics
NPI:1629231113
Name:SPARKS, JENNIE (COTA)
Entity Type:Individual
Prefix:
First Name:JENNIE
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:JEANETTE
Other - Middle Name:SUE
Other - Last Name:LIDDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:COTA
Mailing Address - Street 1:307 PARTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79124-1415
Mailing Address - Country:US
Mailing Address - Phone:806-359-6847
Mailing Address - Fax:
Practice Address - Street 1:1901 MEDI PARK DR
Practice Address - Street 2:SUITE 65
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2110
Practice Address - Country:US
Practice Address - Phone:806-468-7611
Practice Address - Fax:806-468-7603
Is Sole Proprietor?:No
Enumeration Date:2008-07-06
Last Update Date:2008-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX209654224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant