Provider Demographics
NPI:1053721381
Name:RAVEN'S NEST LLC
Entity type:Organization
Organization Name:RAVEN'S NEST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:434-210-0343
Mailing Address - Street 1:1247 FORT MITCHELL DR
Mailing Address - Street 2:
Mailing Address - City:CHASE CITY
Mailing Address - State:VA
Mailing Address - Zip Code:23924-5340
Mailing Address - Country:US
Mailing Address - Phone:434-738-8493
Mailing Address - Fax:
Practice Address - Street 1:1247 FORT MITCHELL DR
Practice Address - Street 2:
Practice Address - City:CHASE CITY
Practice Address - State:VA
Practice Address - Zip Code:23924-5340
Practice Address - Country:US
Practice Address - Phone:434-738-8493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2181320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities