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General NPI Number Information
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NPI Number | 1508621731
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Entity Type | Individual
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Provider Name | EBONY LOUISE JACKSON
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Gender | Female
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Dates
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Enumeration Date | 02/16/2024
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Last Update Date | 02/16/2024
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Provider Practice Location Address
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Address Line | 1711 CENTRAL AVE
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City | SUMMERVILLE
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State | SC
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Zip | 29483-9320
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Country | US
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Telephone | 843-934-1981
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Fax |
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Provider Business Mailing Address
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Address Line | 414 GRAY BARK RD
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City | SUMMERVILLE
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State | SC
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Zip | 29486-8302
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Country | US
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Telephone | 720-827-6055
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106S00000X
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Taxonomy Name | Behavior Technician
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License Number | 23-268294
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License Number State | CO
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