Individual
RAVEN JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1818 SW LESLIE GLN, LAKE CITY, FL 32025-1406
(386) 406-7236
Mailing address
1818 SW LESLIE GLN, LAKE CITY, FL 32025-1406
(386) 406-7236
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
J250-732-83-834-0
FL
3747P1801X
Personal Care Attendant
Primary
CNA-18322
FL
Other
Enumeration date
06/02/2025
Last updated
06/02/2025
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