Provider Demographics
NPI:1689206898
Name:JACKSON, RAYSHARN
Entity Type:Individual
Prefix:
First Name:RAYSHARN
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3607 SILVER PARK DR APT 103
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746-2930
Mailing Address - Country:US
Mailing Address - Phone:301-996-4154
Mailing Address - Fax:
Practice Address - Street 1:4204 E CAPITOL ST NE APT 10
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-4469
Practice Address - Country:US
Practice Address - Phone:301-996-4154
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant