Healthcare Provider Details

I. General information

NPI: 1972496347
Provider Name (Legal Business Name): RAVEN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1818 SW LESLIE GLN
LAKE CITY FL
32025-1406
US

IV. Provider business mailing address

1818 SW LESLIE GLN
LAKE CITY FL
32025-1406
US

V. Phone/Fax

Practice location:
  • Phone: 386-406-7236
  • Fax:
Mailing address:
  • Phone: 386-406-7236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License NumberJ250-732-83-834-0
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License NumberCNA-18322
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: