Provider Demographics
NPI:1972496347
Name:JACKSON, RAVEN
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 SW LESLIE GLN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1406
Mailing Address - Country:US
Mailing Address - Phone:386-406-7236
Mailing Address - Fax:
Practice Address - Street 1:1818 SW LESLIE GLN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1406
Practice Address - Country:US
Practice Address - Phone:386-406-7236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJ250-732-83-834-0172A00000X
FLCNA-183223747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver