Provider Demographics
NPI:1164820163
Name:HARVEY-JACKSON, EBONY (LMSW)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:HARVEY-JACKSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19323 STANSBURY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-1733
Mailing Address - Country:US
Mailing Address - Phone:313-215-6395
Mailing Address - Fax:
Practice Address - Street 1:19323 STANSBURY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-1733
Practice Address - Country:US
Practice Address - Phone:313-215-6395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247000000X
MI68010853191041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical