Healthcare Provider Details

I. General information

NPI: 1588328637
Provider Name (Legal Business Name): EBONY TAMU JACKSON CLTC, CHHA, CCNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2021
Last Update Date: 10/25/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5930 E 31ST ST STE 550
TULSA OK
74135-5121
US

IV. Provider business mailing address

5930 E 31ST ST STE 550
TULSA OK
74135-5121
US

V. Phone/Fax

Practice location:
  • Phone: 918-313-9591
  • Fax:
Mailing address:
  • Phone: 918-313-9591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number37V954550119
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number37V954560119
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License Number37V954550119
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code364SL0600X
TaxonomyLong-Term Care Clinical Nurse Specialist
License Number37V954550119
License Number StateOK
# 5
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number37V954550119
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: