MEDICARE: MR. DRAEVON EDWARD JACKSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	99133860A	IN

General Provider Information

NPI Number	:	1164387072
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DRAEVON EDWARD JACKSON

Provider Business Mailing Address
First Line	:	1927 MONROE ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-1921
Country	:	US
Telephone Number	:	317-772-2830
Fax Number	:

Provider Business Practice Location Address
First Line	:	3777 PRIORITY WAY SOUTH DR
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1491
Country	:	US
Telephone Number	:	317-574-3980
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2025
Last Update Date	:	12/23/2025

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