Provider Demographics
NPI:1053121574
Name:SPARK INTEGRATIVE WELLNESS, PLLC
Entity type:Organization
Organization Name:SPARK INTEGRATIVE WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PMHNP
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:423-491-9146
Mailing Address - Street 1:2700 S ROAN ST STE 300A
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-7556
Mailing Address - Country:US
Mailing Address - Phone:423-722-2422
Mailing Address - Fax:423-722-2400
Practice Address - Street 1:2700 S ROAN ST STE 300A
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-7556
Practice Address - Country:US
Practice Address - Phone:423-722-2422
Practice Address - Fax:423-722-2400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)