Provider Demographics
NPI:1609693662
Name:JACKSON, EBONY ADELE (CRNP)
Entity type:Individual
Prefix:
First Name:EBONY
Middle Name:ADELE
Last Name:JACKSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1198 S GOVERNORS AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-6930
Mailing Address - Country:US
Mailing Address - Phone:302-382-8698
Mailing Address - Fax:302-269-3800
Practice Address - Street 1:1198 S GOVERNORS AVE STE 201
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-6930
Practice Address - Country:US
Practice Address - Phone:302-382-8698
Practice Address - Fax:302-269-3800
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL8-0010677363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health