Provider Demographics
NPI:1164462792
Name:BLACK, JENNIFER (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 WESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4152
Mailing Address - Country:US
Mailing Address - Phone:715-847-2558
Mailing Address - Fax:715-847-2557
Practice Address - Street 1:601 S CENTER AVE
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-3404
Practice Address - Country:US
Practice Address - Phone:715-536-5511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1910OtherWI STATE LIC