Healthcare Provider Details

I. General information

NPI: 1871423384
Provider Name (Legal Business Name): JADE RAVEN JACKSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. JADE RAVEN PREVOT

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

720 SAINT JOHN ST
LAFAYETTE LA
70501-6706
US

IV. Provider business mailing address

104 MANN DR
LAFAYETTE LA
70506-1621
US

V. Phone/Fax

Practice location:
  • Phone: 337-237-2090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberPLC11226
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: