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NPI Code Detail

MEDICARE: EBONY LOUISE JACKSON

MEDICARE: EBONY LOUISE JACKSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician23-268294CO

General Provider Information

NPI Number : 1508621731
Entity Type Code : Individual
Provider Name (Legal Business Name) : EBONY LOUISE JACKSON
Provider Business Mailing Address
First Line : 414 GRAY BARK RD
Second Line :
City : SUMMERVILLE
State : SC
Zip : 29486-8302
Country : US
Telephone Number : 720-827-6055
Fax Number :
Provider Business Practice Location Address
First Line : 1711 CENTRAL AVE
Second Line :
City : SUMMERVILLE
State : SC
Zip : 29483-9320
Country : US
Telephone Number : 843-934-1981
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/16/2024
Last Update Date : 02/16/2024

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Directions to “ EBONY LOUISE JACKSON ” Practice Location

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