Provider Demographics
NPI:1497093116
Name:JACKSON, EBONEY (PHD)
Entity Type:Individual
Prefix:
First Name:EBONEY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6502 NURSERY DR. STE. 100
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904
Mailing Address - Country:US
Mailing Address - Phone:361-575-0611
Mailing Address - Fax:361-579-6913
Practice Address - Street 1:6711 S NEW BRAUNFELS AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78223-3005
Practice Address - Country:US
Practice Address - Phone:210-532-8811
Practice Address - Fax:210-531-8172
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32651103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling