Provider Demographics
NPI:1710161419
Name:EBONY HOUSE INC
Entity Type:Organization
Organization Name:EBONY HOUSE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:CHE
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-276-4528
Mailing Address - Street 1:6222 13TH ST BLDG Y
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042
Mailing Address - Country:US
Mailing Address - Phone:602-276-4288
Mailing Address - Fax:602-232-2938
Practice Address - Street 1:6222 13TH ST BLDG Y
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042
Practice Address - Country:US
Practice Address - Phone:602-276-4288
Practice Address - Fax:602-232-2938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ274629Medicaid
AZ274629OtherAHCCCS