Provider Demographics
NPI:1104553528
Name:JACKSON, EBONI DENICE (AMCA CERTIFIED TRICH)
Entity type:Individual
Prefix:MS
First Name:EBONI
Middle Name:DENICE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:AMCA CERTIFIED TRICH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 TRIANGLE PARK DR # 1900
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3416
Mailing Address - Country:US
Mailing Address - Phone:513-376-7514
Mailing Address - Fax:
Practice Address - Street 1:19 TRIANGLE PARK DR # 1900
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-3416
Practice Address - Country:US
Practice Address - Phone:513-376-7514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner