Basic Information
| Provider Information | |||||||||
| NPI: | 1558670869 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARE | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | SUSZAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 123 N FRONT ST | ||||||||
| Address2: | |||||||||
| City: | WINONA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389672239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622832505 | ||||||||
| FaxNumber: | 6018258130 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 CR 356 | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 389305030 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623923631 | ||||||||
| FaxNumber: | 6018258130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2010 | ||||||||
| LastUpdateDate: | 04/16/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R853566 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 08327741 | 05 | MS | MEDICAID | P01044475 | 01 | MS | RAILROAD MEDICARE | OTHER |