Provider Demographics
NPI:1508655820
Name:SPARKS-JACKSON, KATELYN ALEXIS
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ALEXIS
Last Name:SPARKS-JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13202 FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-4510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13202 FLORENCE AVE
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-4510
Practice Address - Country:US
Practice Address - Phone:562-784-1607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-02
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator