Healthcare Provider Details

I. General information

NPI: 1720970007
Provider Name (Legal Business Name): RAVEN JEFFRIES ABOC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2025
Last Update Date: 07/19/2025
Certification Date: 07/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 TRINITY POINT DR
WASHINGTON PA
15301-2974
US

IV. Provider business mailing address

30 TRINITY POINT DR
WASHINGTON PA
15301-2974
US

V. Phone/Fax

Practice location:
  • Phone: 724-229-7769
  • Fax: 724-229-7792
Mailing address:
  • Phone: 724-229-7769
  • Fax: 724-229-7792

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number257941
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: