Provider Demographics
NPI:1063305068
Name:EBACK, JENNIFER JO
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:EBACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 3RD AVE NE
Mailing Address - Street 2:
Mailing Address - City:DEVILS LAKE
Mailing Address - State:ND
Mailing Address - Zip Code:58301-2113
Mailing Address - Country:US
Mailing Address - Phone:701-230-3223
Mailing Address - Fax:
Practice Address - Street 1:801 3RD AVE NE
Practice Address - Street 2:
Practice Address - City:DEVILS LAKE
Practice Address - State:ND
Practice Address - Zip Code:58301-2113
Practice Address - Country:US
Practice Address - Phone:701-230-3223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant