Provider Demographics
NPI:1972187573
Name:JENERSON, RAVEN EBONI (LICSW)
Entity Type:Individual
Prefix:
First Name:RAVEN
Middle Name:EBONI
Last Name:JENERSON
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 PRESTON RIDGE RD STE 500
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-5460
Mailing Address - Country:US
Mailing Address - Phone:404-969-6116
Mailing Address - Fax:
Practice Address - Street 1:3480 PRESTON RIDGE RD STE 500
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-5460
Practice Address - Country:US
Practice Address - Phone:404-969-6116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-10
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040150071041C0700X
DCLC500828691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical