Provider Demographics
NPI:1932486644
Name:SPARKS, JEANNE KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:KATHLEEN
Last Name:SPARKS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JEANNE
Other - Middle Name:KATHLEEN
Other - Last Name:SEEBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10 FILA WAY
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:MD
Mailing Address - Zip Code:21152-9452
Mailing Address - Country:US
Mailing Address - Phone:410-472-1006
Mailing Address - Fax:410-472-0900
Practice Address - Street 1:10 FILA WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:SPARKS
Practice Address - State:MD
Practice Address - Zip Code:21152-9452
Practice Address - Country:US
Practice Address - Phone:410-472-1006
Practice Address - Fax:410-472-0900
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004611207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD232366ZALXMedicare PIN