Healthcare Provider Details

I. General information

NPI: 1750054748
Provider Name (Legal Business Name): ALEXIS JAGGERS-SPARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

292 S SECOND ST
RICHMOND KY
40475-2102
US

IV. Provider business mailing address

292 S SECOND ST
RICHMOND KY
40475-2102
US

V. Phone/Fax

Practice location:
  • Phone: 859-353-5505
  • Fax: 833-799-3656
Mailing address:
  • Phone: 859-353-5505
  • Fax: 833-799-3656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number296757
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: