Provider Demographics
NPI:1306013305
Name:BLACK, JASON L (APRN-C)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:L
Last Name:BLACK
Suffix:
Gender:M
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1407 W BADDOUR PKWY
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-2513
Mailing Address - Country:US
Mailing Address - Phone:615-444-6203
Mailing Address - Fax:615-444-6252
Practice Address - Street 1:1407 W BADDOUR PKWY
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-2513
Practice Address - Country:US
Practice Address - Phone:615-444-6203
Practice Address - Fax:615-444-6252
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP145757363LF0000X
TN12510363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1524683Medicaid
TN270851352OtherAETNA
TN4298132OtherBCBS
TN1671330OtherCIGNA
TN141492OtherTN REGISTERED NURSE
TN3323078OtherUHC
TN12242516OtherCAQH
TN62-1792161OtherTRICARE
TN12510OtherADVANCED PRACTICE NURSE NUMBER
TN141492OtherTN REGISTERED NURSE