Provider Demographics
NPI:1982142485
Name:JORDEN-LAWAL, EBONY R
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:R
Last Name:JORDEN-LAWAL
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 1:12615 BROOKGLADE CIR UNIT 306
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77099-1389
Mailing Address - Country:US
Mailing Address - Phone:346-309-8288
Mailing Address - Fax:
Practice Address - Street 1:12615 BROOKGLADE CIR UNIT 306
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77099-1389
Practice Address - Country:US
Practice Address - Phone:346-309-8288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX172V00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker