Provider Demographics
NPI:1194227207
Name:BLACK, JODIE (CRNP)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BLACK HORSE PIKE
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:NJ
Mailing Address - Zip Code:08106-1950
Mailing Address - Country:US
Mailing Address - Phone:844-542-2273
Mailing Address - Fax:
Practice Address - Street 1:100 BLACK HORSE PIKE
Practice Address - Street 2:
Practice Address - City:AUDUBON
Practice Address - State:NJ
Practice Address - Zip Code:08106-1950
Practice Address - Country:US
Practice Address - Phone:844-542-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018556207Q00000X
NJ26NJ00805900363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine