Provider Demographics
NPI:1063719136
Name:RAYNYODA JACKSON MED WAVIER AGENCY LLC
Entity type:Organization
Organization Name:RAYNYODA JACKSON MED WAVIER AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAYNYODA
Authorized Official - Middle Name:SHELONDA
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-433-0350
Mailing Address - Street 1:1230 NW 5TH AVE
Mailing Address - Street 2:PO BOX 2634
Mailing Address - City:HIGH SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32643-0418
Mailing Address - Country:US
Mailing Address - Phone:386-433-0350
Mailing Address - Fax:385-454-4288
Practice Address - Street 1:1230 NW 5TH AVE
Practice Address - Street 2:
Practice Address - City:HIGH SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:32643-0418
Practice Address - Country:US
Practice Address - Phone:386-433-0350
Practice Address - Fax:385-454-4288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-25
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
320900000X
FL6906358310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691654696Medicaid
FL691654603Medicaid
FL691654698Medicaid
FL6906358OtherADULT FAMILY CARE HOME PROVIDER LICENSE NUMBER