Provider Demographics
NPI:1194041053
Name:BLACK, JEANNE MARIE
Entity Type:Individual
Prefix:MS
First Name:JEANNE
Middle Name:MARIE
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:PO BOX 801
Mailing Address - Street 2:
Mailing Address - City:TOANO
Mailing Address - State:VA
Mailing Address - Zip Code:23168-0801
Mailing Address - Country:US
Mailing Address - Phone:757-565-1700
Mailing Address - Fax:757-565-6068
Practice Address - Street 1:7151 RICHMOND RD
Practice Address - Street 2:SUITE 401
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23188-7234
Practice Address - Country:US
Practice Address - Phone:757-565-1700
Practice Address - Fax:757-565-6068
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0017000296363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care