Healthcare Provider Details

I. General information

NPI: 1720739337
Provider Name (Legal Business Name): JACK SPARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANE SPARKS

II. Dates (important events)

Enumeration Date: 01/14/2022
Last Update Date: 05/10/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 ENERGY PARK DR
SAINT PAUL MN
55108-5229
US

IV. Provider business mailing address

1515 ENERGY PARK DR
SAINT PAUL MN
55108-5229
US

V. Phone/Fax

Practice location:
  • Phone: 913-328-4708
  • Fax:
Mailing address:
  • Phone: 816-588-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5590
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: