Healthcare Provider Details

I. General information

NPI: 1689365603
Provider Name (Legal Business Name): JENNIFER EBANKS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 08/20/2025
Certification Date: 08/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 PARK AVE
CRANSTON RI
02910-3227
US

IV. Provider business mailing address

275 DULUDE AVE
WOONSOCKET RI
02895-3431
US

V. Phone/Fax

Practice location:
  • Phone: 401-396-7649
  • Fax:
Mailing address:
  • Phone: 774-240-0903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: