Provider Demographics
NPI:1215560545
Name:CRISLER, CHINNIKA LATRICE
Entity Type:Individual
Prefix:
First Name:CHINNIKA
Middle Name:LATRICE
Last Name:CRISLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39204-2841
Mailing Address - Country:US
Mailing Address - Phone:601-948-5572
Mailing Address - Fax:
Practice Address - Street 1:1134 WINTER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-2841
Practice Address - Country:US
Practice Address - Phone:601-948-5572
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC80481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical