Provider Demographics
NPI:1871035394
Name:SMITH, EBONY JOLAN
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:JOLAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8211 SUMMA AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-3471
Mailing Address - Country:US
Mailing Address - Phone:225-761-1970
Mailing Address - Fax:
Practice Address - Street 1:8211 SUMMA AVE
Practice Address - Street 2:SUITE F
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70809
Practice Address - Country:US
Practice Address - Phone:225-761-1970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-15
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator