Provider Demographics
NPI:1336749597
Name:JACKSON, EBONY
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:
Last Name:JACKSON
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 1:15267 MORNING DOVE DR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77396-2294
Mailing Address - Country:US
Mailing Address - Phone:281-736-0806
Mailing Address - Fax:
Practice Address - Street 1:11510 HOMESTEAD RD STE 500
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77016-1239
Practice Address - Country:US
Practice Address - Phone:281-736-0806
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 171M00000X, 374T00000X, 103K00000X
TX794174H00000X, 172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No174H00000XOther Service ProvidersHealth Educator
Yes172V00000XOther Service ProvidersCommunity Health Worker
No374T00000XNursing Service Related ProvidersReligious Nonmedical Nursing Personnel