Provider Demographics
NPI:1871227355
Name:BLACK, JESSICA MILES
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MILES
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 1:142 PINE LAKE RNCH
Mailing Address - Street 2:
Mailing Address - City:BELTON
Mailing Address - State:SC
Mailing Address - Zip Code:29627-8865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:922 HIGHWAY 28 BYP
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29624-1114
Practice Address - Country:US
Practice Address - Phone:864-224-7469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC43510183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist