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General NPI Number Information
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NPI Number | 1124881511
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Entity Type | Individual
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Provider Name | RAVEN DAVON JACKSON MSW
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Gender | Female
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Dates
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Enumeration Date | 01/30/2024
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Last Update Date | 01/30/2024
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Provider Practice Location Address
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Address Line | 620 COLONIAL PARK DR
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City | ROSWELL
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State | GA
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Zip | 30075-3838
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Country | US
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Telephone | 678-834-9242
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Fax |
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Provider Business Mailing Address
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Address Line | 2950 RICHMOND ROW DR UNIT 2214
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City | SUWANEE
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State | GA
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Zip | 30024-7824
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Country | US
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Telephone | 501-944-3160
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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