Healthcare Provider Details

I. General information

NPI: 1497093116
Provider Name (Legal Business Name): EBONEY JACKSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2013
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 S NEW BRAUNFELS AVE SUITE 100
SAN ANTONIO TX
78223-3005
US

IV. Provider business mailing address

6502 NURSERY DR. STE. 100
VICTORIA TX
77904
US

V. Phone/Fax

Practice location:
  • Phone: 210-532-8811
  • Fax: 210-531-8172
Mailing address:
  • Phone: 361-575-0611
  • Fax: 361-579-6913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number32651
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: