Individual
EBONY JACKSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4754 E 175TH ST, CLEVELAND, OH 44128-3932
(216) 856-3107
Mailing address
4754 E 175TH ST, CLEVELAND, OH 44128-3932
(216) 856-3107
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
PN.142392
OH
Other
Enumeration date
11/16/2009
Last updated
01/03/2011
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