Provider Demographics
NPI:1225097090
Name:BLACK, JEAN ANNE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:ANNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 LOOP RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WINNSBORO
Mailing Address - State:LA
Mailing Address - Zip Code:71295-3338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2104 LOOP RD
Practice Address - Street 2:SUITE C
Practice Address - City:WINNSBORO
Practice Address - State:LA
Practice Address - Zip Code:71295-3338
Practice Address - Country:US
Practice Address - Phone:318-435-4571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA50441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical