Provider Demographics
NPI:1568152171
Name:RAYNOR, JACKSON FRIEDRICH (MSW, LGSW)
Entity Type:Individual
Prefix:
First Name:JACKSON
Middle Name:FRIEDRICH
Last Name:RAYNOR
Suffix:
Gender:M
Credentials:MSW, LGSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 E LAFAYETTE FRONTAGE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55107-1216
Mailing Address - Country:US
Mailing Address - Phone:651-602-7552
Mailing Address - Fax:651-602-7580
Practice Address - Street 1:153 CESAR CHAVEZ ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55107-2226
Practice Address - Country:US
Practice Address - Phone:651-602-7500
Practice Address - Fax:651-222-1305
Is Sole Proprietor?:No
Enumeration Date:2023-05-09
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN31487104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker