Provider Demographics
NPI:1124881511
Name:JACKSON, RAVEN DAVON (MSW)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:DAVON
Last Name:JACKSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2950 RICHMOND ROW DR UNIT 2214
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-7824
Mailing Address - Country:US
Mailing Address - Phone:501-944-3160
Mailing Address - Fax:
Practice Address - Street 1:620 COLONIAL PARK DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3838
Practice Address - Country:US
Practice Address - Phone:678-834-9242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker