Healthcare Provider Details

I. General information

NPI: 1245616556
Provider Name (Legal Business Name): MR. CHRISITAN WARE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 LAKELAND DR
JACKSON MS
39216-4719
US

IV. Provider business mailing address

1465 LAKELAND DR
JACKSON MS
39216-4719
US

V. Phone/Fax

Practice location:
  • Phone: 601-352-7784
  • Fax: 601-968-0021
Mailing address:
  • Phone: 601-352-7784
  • Fax: 601-968-0021

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1382
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: