Healthcare Provider Details

I. General information

NPI: 1386424711
Provider Name (Legal Business Name): JONATHAN DELTON STAFFORD CHW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2023
Last Update Date: 10/03/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N JACKSON ST
JACKSON MI
49201-1223
US

IV. Provider business mailing address

2955 PHEASANT RUN DR
JACKSON MI
49202-1344
US

V. Phone/Fax

Practice location:
  • Phone: 517-748-5500
  • Fax:
Mailing address:
  • Phone: 517-885-5238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: