Provider Demographics
NPI:1265854905
Name:BLACK, JEFFREY
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2222 WELBORN ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-3924
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2222 WELBORN ST
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-3924
Practice Address - Country:US
Practice Address - Phone:214-559-8596
Practice Address - Fax:214-559-7808
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH85832080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics