Healthcare Provider Details

I. General information

NPI: 1376008045
Provider Name (Legal Business Name): MRS. ROXANNE WALDRON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ROXANNE SHANKSTER

II. Dates (important events)

Enumeration Date: 02/06/2019
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N WEST AVE STE 300
JACKSON MI
49202-2180
US

IV. Provider business mailing address

126 WILSON ST
MORENCI MI
49256-1130
US

V. Phone/Fax

Practice location:
  • Phone: 517-789-1234
  • Fax: 517-740-7040
Mailing address:
  • Phone: 517-306-3516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: