Provider Demographics
NPI:1033753231
Name:FIFTH CORNER ACADEMY
Entity type:Organization
Organization Name:FIFTH CORNER ACADEMY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROXANNE
Authorized Official - Middle Name:FRANKLIN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA, QMHA, PSS
Authorized Official - Phone:503-714-6306
Mailing Address - Street 1:650 NE 2ND ST UNIT 133
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-4762
Mailing Address - Country:US
Mailing Address - Phone:503-472-4511
Mailing Address - Fax:503-714-6306
Practice Address - Street 1:1900 NE HIGHWAY 99W STE K
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-2757
Practice Address - Country:US
Practice Address - Phone:503-472-4511
Practice Address - Fax:503-714-6306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No172A00000XOther Service ProvidersDriverGroup - Multi-Specialty
No1744R1102XOther Service ProvidersSpecialistResearch StudyGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty
No175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty
No405300000XOther Service ProvidersPrevention ProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1851475099Medicaid