Provider Demographics
NPI:1386424711
Name:STAFFORD, JONATHAN DELTON (CHW)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:DELTON
Last Name:STAFFORD
Suffix:
Gender:M
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 PHEASANT RUN DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1344
Mailing Address - Country:US
Mailing Address - Phone:517-885-5238
Mailing Address - Fax:
Practice Address - Street 1:500 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1223
Practice Address - Country:US
Practice Address - Phone:517-748-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-03
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker