Provider Demographics
NPI:1710347943
Name:BLACK, JENNIFER LEIGH (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16000 CHRISTENSEN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2925
Mailing Address - Country:US
Mailing Address - Phone:702-483-5020
Mailing Address - Fax:
Practice Address - Street 1:16000 CHRISTENSEN RD STE 200
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2925
Practice Address - Country:US
Practice Address - Phone:833-719-0886
Practice Address - Fax:702-589-4872
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA149915363LF0000X
WA70003309-NP363LP0808X
IAG166344363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily