Provider Demographics
NPI:1043360829
Name:BLACK, JEANNA D'ANN (MED, LPC)
Entity type:Individual
Prefix:MS
First Name:JEANNA
Middle Name:D'ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:MS
Other - First Name:D'ANN
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, LPC
Mailing Address - Street 1:1616 S KENTUCKY ST
Mailing Address - Street 2:SUITE C-255
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79102-2252
Mailing Address - Country:US
Mailing Address - Phone:806-331-5738
Mailing Address - Fax:806-331-5738
Practice Address - Street 1:1616 S KENTUCKY ST
Practice Address - Street 2:SUITE C-255
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79102-2252
Practice Address - Country:US
Practice Address - Phone:806-331-5738
Practice Address - Fax:806-331-5738
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14857101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional