1841706520 NPI number — TARAH JEANETTE-GONZALEZ SPARKMAN DPT

Table of content: TARAH JEANETTE-GONZALEZ SPARKMAN DPT (NPI 1841706520)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841706520 NPI number — TARAH JEANETTE-GONZALEZ SPARKMAN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SPARKMAN
Provider First Name:
TARAH
Provider Middle Name:
JEANETTE-GONZALEZ
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GONZALEZ
Provider Other First Name:
TARAH
Provider Other Middle Name:
JEANETTE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1841706520
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 193
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLUE JAY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92317-0193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-754-4097
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27169 CA. HWY 189
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
BLUE JAY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-754-4097
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/18/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  293650 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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