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NPI Code Detail

MEDICARE: EBONY JACKSON

MEDICARE: EBONY JACKSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1164W00000XLicensed Practical NursePN.142392OH

General Provider Information

NPI Number : 1356678197
Entity Type Code : Individual
Provider Name (Legal Business Name) : EBONY JACKSON
Provider Business Mailing Address
First Line : 4754 E 175TH ST
Second Line :
City : CLEVELAND
State : OH
Zip : 44128-3932
Country : US
Telephone Number : 216-856-3107
Fax Number :
Provider Business Practice Location Address
First Line : 4754 E 175TH ST
Second Line :
City : CLEVELAND
State : OH
Zip : 44128-3932
Country : US
Telephone Number : 216-856-3107
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/16/2009
Last Update Date : 01/03/2011

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