Healthcare Provider Details

I. General information

NPI: 1245925544
Provider Name (Legal Business Name): JORDAN SPARKS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3007 2ND ST SE
MOULTRIE GA
31768-6798
US

IV. Provider business mailing address

PO BOX 2876
MOULTRIE GA
31776-2876
US

V. Phone/Fax

Practice location:
  • Phone: 229-891-3325
  • Fax: 229-890-8702
Mailing address:
  • Phone: 229-891-3325
  • Fax: 229-890-8702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number11552
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License Number11552
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: