MEDICARE: FIFTH CORNER ACADEMY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	101YM0800X	Mental Health Counselor
2	133NN1002X	Nutrition Education Nutritionist
3	163W00000X	Registered Nurse
4	171M00000X	Case Manager/Care Coordinator
5	172A00000X	Driver
6	1744R1102X	Research Study Specialist
7	174H00000X	Health Educator
8	175T00000X	Peer Specialist
9	405300000X	Prevention Professional
10	2084P0804X	Child & Adolescent Psychiatry Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033753231
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIFTH CORNER ACADEMY

Provider Business Mailing Address
First Line	:	650 NE 2ND ST UNIT 133
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-4762
Country	:	US
Telephone Number	:	503-472-4511
Fax Number	:	503-714-6306

Provider Business Practice Location Address
First Line	:	1900 NE HIGHWAY 99W STE K
Second Line	:
City	:	MCMINNVILLE
State	:	OR
Zip	:	97128-2757
Country	:	US
Telephone Number	:	503-472-4511
Fax Number	:	503-714-6306

Authorized Official
Title or Position	:	PRESIDENT/PROGRAM ADMINISTRATOR
Name	:	MRS. ROXANNE FRANKLIN WILSON
Credential	:	BA, QMHA, PSS
Telephone Number	:	503-714-6306

Provider Enumeration Date	:	10/30/2019
Last Update Date	:	03/28/2020

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Practice Fax: 503-714-6306

Directions to “FIFTH CORNER ACADEMY ” Practice Location

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