MEDICARE: MISS JENNA L SPARKS LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MT-08278	AZ

General Provider Information

NPI Number	:	1194041061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS JENNA L SPARKS LMT

Provider Business Mailing Address
First Line	:	9191 W THUNDERBIRD RD STE 108
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85381-4270
Country	:	US
Telephone Number	:	623-974-3511
Fax Number	:	623-444-9741

Provider Business Practice Location Address
First Line	:	9191 W THUNDERBIRD RD STE 108
Second Line	:
City	:	PEORIA
State	:	AZ
Zip	:	85381-4270
Country	:	US
Telephone Number	:	623-974-3511
Fax Number	:	623-444-9741

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/15/2010
Last Update Date	:	04/15/2010

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