Provider Demographics
NPI:1588328637
Name:JACKSON, EBONY TAMU (CLTC, CHHA, CCNA)
Entity type:Individual
Prefix:MRS
First Name:EBONY
Middle Name:TAMU
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CLTC, CHHA, CCNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5930 E 31ST ST STE 550
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5121
Mailing Address - Country:US
Mailing Address - Phone:918-313-9591
Mailing Address - Fax:
Practice Address - Street 1:5930 E 31ST ST STE 550
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5121
Practice Address - Country:US
Practice Address - Phone:918-313-9591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-25
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37V954550119364SG0600X, 364SL0600X, 174400000X
OK37V954560119253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontologyGroup - Multi-Specialty
No364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term CareGroup - Multi-Specialty