Provider Demographics
NPI:1821470188
Name:EBONY C JACKSON LLC
Entity Type:Organization
Organization Name:EBONY C JACKSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MISS
Authorized Official - First Name:EBONY
Authorized Official - Middle Name:CONERLY
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, BACS
Authorized Official - Phone:225-284-6249
Mailing Address - Street 1:23791 SOUTHPOINT DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-6856
Mailing Address - Country:US
Mailing Address - Phone:225-369-2617
Mailing Address - Fax:
Practice Address - Street 1:23791 SOUTHPOINT DR
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-6856
Practice Address - Country:US
Practice Address - Phone:225-369-2617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9158261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health