Provider Demographics
NPI:1134830623
Name:JACKMAN-EL, RAVANNA
Entity type:Individual
Prefix:
First Name:RAVANNA
Middle Name:
Last Name:JACKMAN-EL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21231-1712
Mailing Address - Country:US
Mailing Address - Phone:667-234-0430
Mailing Address - Fax:
Practice Address - Street 1:14 S BROADWAY
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21231-1712
Practice Address - Country:US
Practice Address - Phone:667-234-0430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDPR0584175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist