Provider Demographics
NPI:1255903837
Name:SPARKS, JEREMY
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:SPARKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 S STATE ROUTE 202
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-9638
Mailing Address - Country:US
Mailing Address - Phone:937-219-9210
Mailing Address - Fax:
Practice Address - Street 1:2150 MONTEGO DR
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-6464
Practice Address - Country:US
Practice Address - Phone:937-219-9210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.410677163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse