Provider Demographics
NPI:1447949946
Name:BLACK, JENNIFER LYNN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:BLACK
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 1:4428 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4264
Mailing Address - Country:US
Mailing Address - Phone:419-290-1495
Mailing Address - Fax:
Practice Address - Street 1:4428 SECOR RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4264
Practice Address - Country:US
Practice Address - Phone:419-290-1495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-02
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst