Basic Information
| Provider Information | |||||||||
| NPI: | 1205260486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACKSON | ||||||||
| FirstName: | EBONY | ||||||||
| MiddleName: | NECHOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1625 E G ST | ||||||||
| Address2: | APT 8B | ||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917645406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082287383 | ||||||||
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| Practice Location | |||||||||
| Address1: | 317 W F ST | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917623205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099867111 | ||||||||
| FaxNumber: | 9099860941 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2013 | ||||||||
| LastUpdateDate: | 08/28/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.