Provider Demographics
NPI:1225636582
Name:JACKSON, EBONY JAMICE (RN)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:JAMICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:EBONY
Other - Middle Name:JAMICE
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3601 SHADY TIMBER DR
Mailing Address - Street 2:
Mailing Address - City:TWINSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:44087-4945
Mailing Address - Country:US
Mailing Address - Phone:216-296-4817
Mailing Address - Fax:
Practice Address - Street 1:3601 SHADY TIMBER DR
Practice Address - Street 2:
Practice Address - City:TWINSBURG
Practice Address - State:OH
Practice Address - Zip Code:44087-4945
Practice Address - Country:US
Practice Address - Phone:216-296-4817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.346657163WC0400X, 163WG0600X, 163WM0705X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Single Specialty