Provider Demographics
NPI:1376102723
Name:CALLENDER, JACLYN DANIELLE
Entity Type:Individual
Prefix:
First Name:JACLYN
Middle Name:DANIELLE
Last Name:CALLENDER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JACLYN
Other - Middle Name:DANIELLE
Other - Last Name:ROGGENBUCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1375 R DALE WERTZ DR
Mailing Address - Street 2:
Mailing Address - City:BAD AXE
Mailing Address - State:MI
Mailing Address - Zip Code:48413-1365
Mailing Address - Country:US
Mailing Address - Phone:989-269-9293
Mailing Address - Fax:
Practice Address - Street 1:1375 R DALE WERTZ DR
Practice Address - Street 2:
Practice Address - City:BAD AXE
Practice Address - State:MI
Practice Address - Zip Code:48413-1365
Practice Address - Country:US
Practice Address - Phone:989-269-9293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011112871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical