Provider Demographics
NPI:1154649457
Name:BLACK, JENNIFER LYNN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LYNN
Last Name:BLACK
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6106 N NAVARRO ST
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-1769
Mailing Address - Country:US
Mailing Address - Phone:361-572-8575
Mailing Address - Fax:361-578-5476
Practice Address - Street 1:6106 N NAVARRO ST
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-1769
Practice Address - Country:US
Practice Address - Phone:361-572-8575
Practice Address - Fax:361-578-5476
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29863183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist