Healthcare Provider Details

I. General information

NPI: 1376102723
Provider Name (Legal Business Name): JACLYN DANIELLE CALLENDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACLYN DANIELLE ROGGENBUCK

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1375 R DALE WERTZ DR
BAD AXE MI
48413-1365
US

IV. Provider business mailing address

1375 R DALE WERTZ DR
BAD AXE MI
48413-1365
US

V. Phone/Fax

Practice location:
  • Phone: 989-269-9293
  • Fax:
Mailing address:
  • Phone: 989-269-9293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801111287
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: