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General NPI Number Information
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NPI Number | 1245925544
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Entity Type | Individual
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Provider Name | JORDAN SPARKS PA-C
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Gender | Male
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Dates
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Enumeration Date | 04/11/2023
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Last Update Date | 03/05/2026
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Provider Practice Location Address
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Address Line | 3007 2ND ST SE
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City | MOULTRIE
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State | GA
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Zip | 31768-6798
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Country | US
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Telephone | 229-891-3325
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Fax | 229-890-8702
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Provider Business Mailing Address
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Address Line | PO BOX 2876
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City | MOULTRIE
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State | GA
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Zip | 31776-2876
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Country | US
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Telephone | 229-891-3325
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Fax | 229-890-8702
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 246ZX2200X
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Taxonomy Name | Orthopedic Assistant
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License Number | 11552
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 11552
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License Number State | GA
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