Provider Demographics
NPI:1356638910
Name:BLACK, JENNIFER MICHELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:COUNCIL BLUFFS
Mailing Address - State:IA
Mailing Address - Zip Code:51503-5300
Mailing Address - Country:US
Mailing Address - Phone:712-326-5340
Mailing Address - Fax:
Practice Address - Street 1:233 S 13TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68508-2017
Practice Address - Country:US
Practice Address - Phone:712-326-5340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE78791223G0001X
IA088311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice