Healthcare Provider Details

I. General information

NPI: 1477101681
Provider Name (Legal Business Name): MEGHAN WAGGONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2019
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1211 W NORTH ST
JACKSON MI
49202-3132
US

IV. Provider business mailing address

2400 SCIENCE PKWY
OKEMOS MI
48864-2560
US

V. Phone/Fax

Practice location:
  • Phone: 517-513-3297
  • Fax:
Mailing address:
  • Phone: 517-374-8066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401003426
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: