Healthcare Provider Details

I. General information

NPI: 1659140465
Provider Name (Legal Business Name): LAQUNANA WILLIAMS CISTRUNK LCSW, LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAQUNANA CISTRUNK LCSW, LISW

II. Dates (important events)

Enumeration Date: 12/21/2023
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3502 W NORTHSIDE DR
JACKSON MS
39213-4454
US

IV. Provider business mailing address

1027 MADISON ST
JACKSON MS
39202-2725
US

V. Phone/Fax

Practice location:
  • Phone: 601-362-5321
  • Fax:
Mailing address:
  • Phone: 812-538-9088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12671-C
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-11480
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number133686
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW04031
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: