Provider Demographics
NPI:1700094653
Name:SPARKS, JACQUELINE MERRILL (OTR-L)
Entity Type:Individual
Prefix:MISS
First Name:JACQUELINE
Middle Name:MERRILL
Last Name:SPARKS
Suffix:
Gender:F
Credentials:OTR-L
Other - Prefix:MISS
Other - First Name:JACQUELINE
Other - Middle Name:ANN
Other - Last Name:MERRILL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OTR-L
Mailing Address - Street 1:127 BROWNFIELD RD
Mailing Address - Street 2:
Mailing Address - City:EATON CENTER
Mailing Address - State:NH
Mailing Address - Zip Code:03832-0028
Mailing Address - Country:US
Mailing Address - Phone:603-447-5972
Mailing Address - Fax:
Practice Address - Street 1:182 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:NH
Practice Address - Zip Code:03818-6140
Practice Address - Country:US
Practice Address - Phone:603-447-6356
Practice Address - Fax:603-447-1114
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0389225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist