Provider Demographics
NPI:1780041384
Name:SPARKS, JENNIFER (FNP-CNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:FNP-CNP
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 1213
Mailing Address - Street 2:
Mailing Address - City:LAVERNE
Mailing Address - State:OK
Mailing Address - Zip Code:73848-1213
Mailing Address - Country:US
Mailing Address - Phone:580-254-5322
Mailing Address - Fax:
Practice Address - Street 1:718 AVENUE A
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:OK
Practice Address - Zip Code:73932-3101
Practice Address - Country:US
Practice Address - Phone:580-625-3477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2021-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR 0071514163W00000X
OK205506363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse