Healthcare Provider Details

I. General information

NPI: 1043740988
Provider Name (Legal Business Name): JONATHAN F SPARKS LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2017
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 EDITH BLVD NE
ALBUQUERQUE NM
87107-2222
US

IV. Provider business mailing address

4000 EDITH BLVD NE
ALBUQUERQUE NM
87107-2222
US

V. Phone/Fax

Practice location:
  • Phone: 505-469-2272
  • Fax:
Mailing address:
  • Phone: 505-469-2272
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2023-0098
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: