Healthcare Provider Details

I. General information

NPI: 1063719136
Provider Name (Legal Business Name): RAYNYODA JACKSON MED WAVIER AGENCY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2011
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 NW 5TH AVE
HIGH SPRINGS FL
32643-0418
US

IV. Provider business mailing address

1230 NW 5TH AVE PO BOX 2634
HIGH SPRINGS FL
32643-0418
US

V. Phone/Fax

Practice location:
  • Phone: 386-433-0350
  • Fax: 385-454-4288
Mailing address:
  • Phone: 386-433-0350
  • Fax: 385-454-4288

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number6906358
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MRS. RAYNYODA SHELONDA JACKSON
Title or Position: PROVIDER
Credential:
Phone: 386-433-0350