Provider Demographics
NPI:1639782907
Name:SPARKS, JENNA RENEE (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:RENEE
Last Name:SPARKS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:OTTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6638 CAPE NEDDICK CT APT J
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46217-8772
Mailing Address - Country:US
Mailing Address - Phone:812-774-6752
Mailing Address - Fax:
Practice Address - Street 1:1801 N SENATE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1245
Practice Address - Country:US
Practice Address - Phone:317-944-9400
Practice Address - Fax:317-963-3289
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36003333A2080S0010X, 2083S0010X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No2083S0010XAllopathic & Osteopathic PhysiciansPreventive MedicineSports Medicine