Organization
RAYNYODA JACKSON MED WAVIER AGENCY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. RAYNYODA SHELONDA JACKSON (PROVIDER)
(386) 433-0350
Entity
Organization
Contact information
Practice address
1230 NW 5TH AVE, HIGH SPRINGS, FL 32643-0418
(386) 433-0350
(385) 454-4288
Mailing address
1230 NW 5TH AVE, PO BOX 2634, HIGH SPRINGS, FL 32643-0418
(386) 433-0350
(385) 454-4288
Taxonomy
Speciality
Code
Description
License number
State
310400000X
Assisted Living Facility
Primary
6906358
FL
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
6906358
ADULT FAMILY CARE HOME PROVIDER LICENSE NUMBER
FL
05
—
691654603
—
FL
05
—
691654696
—
FL
05
—
691654698
—
FL
Enumeration date
02/25/2011
Last updated
02/25/2011
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