Healthcare Provider Details

I. General information

NPI: 1225286230
Provider Name (Legal Business Name): JEANIE WARREN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2008
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8626 AIRWAYS BLVD
SOUTHAVEN MS
38671-2603
US

IV. Provider business mailing address

8626 AIRWAYS BLVD
SOUTHAVEN MS
38671-2603
US

V. Phone/Fax

Practice location:
  • Phone: 662-772-5937
  • Fax: 662-772-5940
Mailing address:
  • Phone: 662-772-5937
  • Fax: 662-772-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberC-10834
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6286
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: