Provider Demographics
NPI:1558079905
Name:JACKSON, EBONY DENASHIA (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:DENASHIA
Last Name:JACKSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:MS
Other - First Name:EBONY
Other - Middle Name:DENASHIA
Other - Last Name:LARRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3773 62ND ST N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1618
Mailing Address - Country:US
Mailing Address - Phone:727-768-3734
Mailing Address - Fax:
Practice Address - Street 1:3773 62ND ST N
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1618
Practice Address - Country:US
Practice Address - Phone:727-768-3734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-14
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9534481163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health