Healthcare Provider Details

I. General information

NPI: 1063358281
Provider Name (Legal Business Name): KRISTOPHER TREDEL BURNETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5888 RIDGEWOOD RD STE A
JACKSON MS
39211-2644
US

IV. Provider business mailing address

5888 RIDGEWOOD RD STE A
JACKSON MS
39211-2644
US

V. Phone/Fax

Practice location:
  • Phone: 601-313-9307
  • Fax: 769-487-9922
Mailing address:
  • Phone: 601-313-9307
  • Fax: 769-487-9922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3452
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: