Provider Demographics
NPI:1407416886
Name:BLACK, JENNA (CTRS, CBIS ATRIC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:CTRS, CBIS ATRIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28328 N SKYE DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-5335
Mailing Address - Country:US
Mailing Address - Phone:586-709-8966
Mailing Address - Fax:
Practice Address - Street 1:28328 N SKYE DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-5335
Practice Address - Country:US
Practice Address - Phone:586-709-8966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist