Provider Demographics
NPI:1245616556
Name:WARE, CHRISITAN
Entity Type:Individual
Prefix:MR
First Name:CHRISITAN
Middle Name:
Last Name:WARE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 LAKELAND DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4719
Mailing Address - Country:US
Mailing Address - Phone:601-352-7784
Mailing Address - Fax:601-968-0021
Practice Address - Street 1:1465 LAKELAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4719
Practice Address - Country:US
Practice Address - Phone:601-352-7784
Practice Address - Fax:601-968-0021
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1382101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health