Healthcare Provider Details

I. General information

NPI: 1518796770
Provider Name (Legal Business Name): MR. JACK ROBERT SPARAGNA I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MR. JACK ROBERT SPARAGNA I

II. Dates (important events)

Enumeration Date: 07/27/2024
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4164 BROCKTON AVE
RIVERSIDE CA
92501-3400
US

IV. Provider business mailing address

4164 BROCKTON AVE
RIVERSIDE CA
92501-3400
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-5193
  • Fax:
Mailing address:
  • Phone: 951-683-5193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number138653
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: