Individual
EBONI MADLOCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1081 AUTUMN ST, JACKSON, MS 39212-2555
(601) 874-5741
Mailing address
1081 AUTUMN ST, JACKSON, MS 39212-2555
Taxonomy
Speciality
Code
Description
License number
State
225X00000X
Occupational Therapist
117075
TX
225X00000X
Occupational Therapist
Primary
3294
MS
Other
Enumeration date
08/05/2015
Last updated
06/21/2021
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