Provider Demographics
NPI:1760059497
Name:SPARKS, JESSICA (APRN)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:784 HIGHWAY 36
Mailing Address - Street 2:
Mailing Address - City:FRENCHBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40322-8123
Mailing Address - Country:US
Mailing Address - Phone:606-768-9190
Mailing Address - Fax:606-768-9180
Practice Address - Street 1:784 HIGHWAY 36
Practice Address - Street 2:
Practice Address - City:FRENCHBURG
Practice Address - State:KY
Practice Address - Zip Code:40322-8123
Practice Address - Country:US
Practice Address - Phone:606-768-9190
Practice Address - Fax:606-768-9180
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3015405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100749550Medicaid