MEDICARE: RAVEN 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	172A00000X	Driver	J250-732-83-834-0	FL
2	3747P1801X	Personal Care Attendant	CNA-18322	FL

General Provider Information

NPI Number	:	1972496347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAVEN JACKSON

Provider Business Mailing Address
First Line	:	1818 SW LESLIE GLN
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-1406
Country	:	US
Telephone Number	:	386-406-7236
Fax Number	:

Provider Business Practice Location Address
First Line	:	1818 SW LESLIE GLN
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-1406
Country	:	US
Telephone Number	:	386-406-7236
Fax Number	:

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

Provider Enumeration Date	:	06/02/2025
Last Update Date	:	06/02/2025

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Directions to “ RAVEN JACKSON ” Practice Location

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