Active NPI
Eboni Shantelle Jackson
- Peer Specialist
- Cody, WY
National Provider Identifier
1265229595
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Peer Specialist
- License
- 190
- Practice address
- 707 Sheridan Ave
Cody, WY 82414-3409 - Phone
- (307) 578-2486
- Fax
- (307) 578-2247
- NPI assigned
- Apr 21, 2025
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Peer Specialist | 175T00000X | 190 | WY | Primary |
Addresses
Primary practice location
707 Sheridan Ave
Cody, WY 82414-3409
Mailing address
707 Sheridan Ave
Cody, WY 82414-3409
Phone (307) 578-2486
Other practice location 1
125 S Division St
Powell, WY 82435-2409
Phone (307) 754-7970
Other practice location 2
507 N Clark St
Powell, WY 82435-1915
Phone (307) 754-7970
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 190 | WY | MD | Peer Specialist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Chrysalis Treatment Center, Inc. | Past | Accepting new patients | |
| Positive Progressions, LLC | Past | Accepting new patients |
Organizations & group practices 2
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.
-
- Substance Use Disorder Rehabilitation Clinic/Center
- Powell, WY
- NPI 1558837682
-
- Clinical Social Worker
- Powell, WY
- NPI 1477716470
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1745193600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1772668800000",
"number": "1265229595",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "707 SHERIDAN AVE",
"city": "CODY",
"state": "WY",
"postal_code": "824143409",
"telephone_number": "307-578-2486",
"fax_number": "307-578-2247"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "707 SHERIDAN AVE",
"city": "CODY",
"state": "WY",
"postal_code": "824143409",
"telephone_number": "307-578-2486",
"fax_number": "307-578-2247"
}
],
"practiceLocations": [
{
"address_1": "125 S Division St",
"address_purpose": "LOCATION",
"city": "Powell",
"state": "WY",
"postal_code": "824352409",
"country_code": "US",
"telephone_number": "307-754-7970",
"fax_number": "307-333-0470",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "507 N Clark St",
"address_purpose": "LOCATION",
"city": "Powell",
"state": "WY",
"postal_code": "824351915",
"country_code": "US",
"telephone_number": "307-754-7970",
"fax_number": "307-333-0470",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "JACKSON",
"first_name": "EBONI",
"middle_name": "SHANTELLE",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2025-04-21",
"last_updated": "2026-03-05",
"certification_date": "2026-03-05",
"status": "A"
},
"taxonomies": [
{
"code": "175T00000X",
"taxonomy_group": "",
"desc": "Peer Specialist",
"state": "WY",
"license": "190",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Cody, WY
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 5, 2026; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.