Provider Demographics
NPI:1336102607
Name:BLACK, JESSICA ANNE
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:ANNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:GIAMMALVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:9302 N MERIDIAN ST STE 190
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1818
Practice Address - Country:US
Practice Address - Phone:317-843-1270
Practice Address - Fax:317-843-4174
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5296225X00000X, 225XH1200X
IN31005917A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN555850076OtherMEDICARE PTAN
P00263219OtherRAILROAD MEDICARE
IN555850076OtherMEDICARE PTAN