Healthcare Provider Details

I. General information

NPI: 1013478643
Provider Name (Legal Business Name): MAKESHIA WARDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 PINE LN
JACKSON MS
39212-3563
US

IV. Provider business mailing address

655 PINE LN
JACKSON MS
39212-3563
US

V. Phone/Fax

Practice location:
  • Phone: 769-243-3372
  • Fax:
Mailing address:
  • Phone: 769-243-3372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number3057
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: