Healthcare Provider Details

I. General information

NPI: 1699689489
Provider Name (Legal Business Name): CHIQUITA M WILLINGHAM CPT, CET
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5846 RIDGEWOOD RD STE C101
JACKSON MS
39211-2646
US

IV. Provider business mailing address

224 PINE RIDGE RD
JACKSON MS
39206-3945
US

V. Phone/Fax

Practice location:
  • Phone: 769-770-1310
  • Fax:
Mailing address:
  • Phone: 769-901-4905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number50073275
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: