Provider Demographics
NPI:1740985209
Name:JACKSON, EBONE
Entity type:Individual
Prefix:
First Name:EBONE
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 1:4755 LINGLESTOWN RD STE 206
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17112-8547
Mailing Address - Country:US
Mailing Address - Phone:717-400-1871
Mailing Address - Fax:717-814-5260
Practice Address - Street 1:4755 LINGLESTOWN RD STE 206
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17112-8547
Practice Address - Country:US
Practice Address - Phone:717-400-1871
Practice Address - Fax:717-814-5260
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-04
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASW139545101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health