Provider Demographics
NPI:1568025807
Name:JACKSON, EBONY (LCSW)
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:JACKSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6060 CELTIC ASH AVE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1795
Mailing Address - Country:US
Mailing Address - Phone:859-209-6823
Mailing Address - Fax:
Practice Address - Street 1:1655 BURLINGTON PIKE STE 101
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-4909
Practice Address - Country:US
Practice Address - Phone:859-992-2692
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2538051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical