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General NPI Number Information
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NPI Number | 1568025807
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Entity Type | Individual
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Provider Name | EBONY JACKSON LCSW
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Gender | Female
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Dates
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Enumeration Date | 04/22/2019
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Last Update Date | 01/14/2021
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Provider Practice Location Address
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Address Line | 1655 BURLINGTON PIKE STE 101
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City | FLORENCE
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State | KY
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Zip | 41042-4909
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Country | US
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Telephone | 859-992-2692
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Fax |
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Provider Business Mailing Address
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Address Line | 6060 CELTIC ASH AVE
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City | FLORENCE
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State | KY
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Zip | 41042-1795
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Country | US
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Telephone | 859-209-6823
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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 | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 253805
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License Number State | KY
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