Healthcare Provider Details

I. General information

NPI: 1528080561
Provider Name (Legal Business Name): SHERRY V. SPARKS, LCSW, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 E RIVER PL SUITE 504
JACKSON MS
39202-3493
US

IV. Provider business mailing address

840 E RIVER PL SUITE 504
JACKSON MS
39202-3493
US

V. Phone/Fax

Practice location:
  • Phone: 601-383-8089
  • Fax: 601-969-7160
Mailing address:
  • Phone: 601-383-8089
  • Fax: 601-969-7160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC7419
License Number StateMS

VIII. Authorized Official

Name: SHERRY V. SPARKS
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: M.S.W., L.C.S.W.
Phone: 601-383-8089