Healthcare Provider Details

I. General information

NPI: 1942033238
Provider Name (Legal Business Name): AVIS SPARKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 MARQUETTE RD
BRANDON MS
39042-3038
US

IV. Provider business mailing address

4141 CRANE BLVD
JACKSON MS
39216-3406
US

V. Phone/Fax

Practice location:
  • Phone: 601-824-1692
  • Fax:
Mailing address:
  • Phone: 601-622-5283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: