Individual
EBONI SHANTELLE JACKSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
707 SHERIDAN AVE, CODY, WY 82414-3409
(307) 578-2486
(307) 578-2247
Mailing address
707 SHERIDAN AVE, CODY, WY 82414-3409
(307) 578-2486
(307) 578-2247
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
190
WY
Other
Enumeration date
04/21/2025
Last updated
03/05/2026
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