Provider Demographics
NPI:1720739337
Name:SPARKS, JACK
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:SPARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JANE
Other - Middle Name:
Other - Last Name:SPARKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7732 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64114-1730
Mailing Address - Country:US
Mailing Address - Phone:816-588-9591
Mailing Address - Fax:
Practice Address - Street 1:7840 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66112-2152
Practice Address - Country:US
Practice Address - Phone:913-328-4708
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS03989101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional