Provider Demographics
NPI:1558670869
Name:WARE, JACQUELINE SUSZAN (FNP)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:SUSZAN
Last Name:WARE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 N FRONT ST
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MS
Mailing Address - Zip Code:38967-2239
Mailing Address - Country:US
Mailing Address - Phone:662-283-2505
Mailing Address - Fax:601-825-8130
Practice Address - Street 1:112 CR 356
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:MS
Practice Address - Zip Code:38930-5030
Practice Address - Country:US
Practice Address - Phone:662-392-3631
Practice Address - Fax:601-825-8130
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08327741Medicaid
MSP01044475OtherRAILROAD MEDICARE
MSP01044475OtherRAILROAD MEDICARE