Provider Demographics
NPI:1326362666
Name:JACKSON, EBONY L
Entity Type:Individual
Prefix:MS
First Name:EBONY
Middle Name:L
Last Name:JACKSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 N ARSENAL AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-3808
Mailing Address - Country:US
Mailing Address - Phone:317-632-0123
Mailing Address - Fax:317-632-4362
Practice Address - Street 1:26 N ARSENAL AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-3808
Practice Address - Country:US
Practice Address - Phone:317-632-0123
Practice Address - Fax:317-632-4362
Is Sole Proprietor?:No
Enumeration Date:2010-03-16
Last Update Date:2011-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200966040Medicaid