Provider Demographics
NPI:1922508050
Name:JASPER, EBONY L
Entity Type:Individual
Prefix:MS
First Name:EBONY
Middle Name:L
Last Name:JASPER
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 1:1432 PENHURST DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8165
Mailing Address - Country:US
Mailing Address - Phone:678-830-6632
Mailing Address - Fax:
Practice Address - Street 1:1432 PENHURST DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-8165
Practice Address - Country:US
Practice Address - Phone:678-830-6632
Practice Address - Fax:678-830-6632
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP004108235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist