Provider Demographics
NPI:1376872754
Name:BLACK, JENNIFER A
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT #7103
Mailing Address - Street 1:3809 ATRISCO DR NW
Mailing Address - Street 2:SUITE C
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4902
Mailing Address - Country:US
Mailing Address - Phone:505-615-3487
Mailing Address - Fax:505-352-8966
Practice Address - Street 1:3809 ATRISCO DR NW
Practice Address - Street 2:SUITE C
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-4902
Practice Address - Country:US
Practice Address - Phone:505-615-3487
Practice Address - Fax:505-352-8966
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-15
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7301225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist