Provider Demographics
NPI:1134305337
Name:BLACK, JESSICA K (ND)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:K
Last Name:BLACK
Suffix:
Gender:F
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:330 SE BAKER ST
Mailing Address - Street 2:UNIT 3
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6038
Mailing Address - Country:US
Mailing Address - Phone:503-883-0333
Mailing Address - Fax:503-883-0330
Practice Address - Street 1:330 SE BAKER ST
Practice Address - Street 2:UNIT 3
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6038
Practice Address - Country:US
Practice Address - Phone:503-883-0333
Practice Address - Fax:503-883-0330
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2013-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1263175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR234882Medicaid