Raynyoda Jackson Med Wavier Agency LLC

Primary specialty

Assisted Living FacilityTaxonomy code 310400000X

License

6906358 Issued in FL

Legal business name

RAYNYODA JACKSON MED WAVIER AGENCY LLC

Practice address

1230 NW 5TH Ave
High Springs, FL 32643-0418

Phone

(386) 433-0350

Fax

(385) 454-4288

NPI assigned

Feb 25, 2011

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Raynyoda Shelonda Jackson

Title

Provider

Phone

(386) 433-0350

Specialties & licenses 2

Addresses

Other identifiers 4

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1298592000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1298592000000",
    "number": "1063719136",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1230 NW 5TH AVE",
            "address_2": "PO BOX 2634",
            "city": "HIGH SPRINGS",
            "state": "FL",
            "postal_code": "326430418",
            "telephone_number": "386-433-0350",
            "fax_number": "385-454-4288"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1230 NW 5TH AVE",
            "city": "HIGH SPRINGS",
            "state": "FL",
            "postal_code": "326430418",
            "telephone_number": "386-433-0350",
            "fax_number": "385-454-4288"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "RAYNYODA JACKSON MED WAVIER AGENCY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-02-25",
        "last_updated": "2011-02-25",
        "status": "A",
        "authorized_official_last_name": "JACKSON",
        "authorized_official_first_name": "RAYNYODA",
        "authorized_official_middle_name": "SHELONDA",
        "authorized_official_title_or_position": "PROVIDER",
        "authorized_official_telephone_number": "386-433-0350",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "310400000X",
            "taxonomy_group": "",
            "desc": "Assisted Living Facility",
            "state": "FL",
            "license": "6906358",
            "primary": true
        },
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "691654696",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "691654603",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "691654698",
            "state": "FL"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ADULT FAMILY CARE HOME PROVIDER LICENSE NUMBER",
            "identifier": "6906358",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Assisted Living Facility in High Springs, FL
• Providers in High Springs, FL by specialty
• Assisted Living Facility in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 25, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.