Provider Demographics
NPI:1205130390
Name:SPARKS, JERRI (MCD)
Entity type:Individual
Prefix:
First Name:JERRI
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:MCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4112 WALTERS RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9026
Mailing Address - Country:US
Mailing Address - Phone:870-377-0323
Mailing Address - Fax:
Practice Address - Street 1:1900 STILLWATER DR
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72404-9119
Practice Address - Country:US
Practice Address - Phone:870-932-3600
Practice Address - Fax:870-931-4201
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR186685721Medicaid