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Individual

EBONY LOUISE JACKSON

Active
Sole proprietor
No

Provider details

NPI number
Gender
F

Contact information

Practice address
1711 CENTRAL AVE, SUMMERVILLE, SC 29483-9320
(843) 934-1981
Mailing address
414 GRAY BARK RD, SUMMERVILLE, SC 29486-8302
(720) 827-6055

Taxonomy

Speciality
Code
Description
License number
State
106S00000X
Behavior Technician
Primary
23-268294
CO

Other

Enumeration date
02/16/2024
Last updated
02/16/2024
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