Provider Demographics
NPI:1336798511
Name:JOHNSON, EBONY L (PT)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:L
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:EBONY
Other - Middle Name:L
Other - Last Name:MARSHALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1115 FAIRGROUNDS RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5443
Mailing Address - Country:US
Mailing Address - Phone:573-634-3070
Mailing Address - Fax:573-636-3247
Practice Address - Street 1:1115 FAIRGROUNDS RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5443
Practice Address - Country:US
Practice Address - Phone:573-634-3070
Practice Address - Fax:573-636-3247
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019020760225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist