Provider Demographics
NPI:1134227440
Name:SPARKS, JIM ROBERT (PHD)
Entity type:Individual
Prefix:DR
First Name:JIM
Middle Name:ROBERT
Last Name:SPARKS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 COMMERCIAL ST
Mailing Address - Street 2:SUITE 401B
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-6603
Mailing Address - Country:US
Mailing Address - Phone:207-772-0337
Mailing Address - Fax:207-772-0308
Practice Address - Street 1:225 COMMERCIAL ST
Practice Address - Street 2:SUITE 401B
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-6603
Practice Address - Country:US
Practice Address - Phone:207-772-0337
Practice Address - Fax:207-772-0308
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS1244103TC0700X
CAPSY15376103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical