Provider Demographics
NPI:1417938416
Name:BLACK, JEAN MARIE (NP)
Entity Type:Individual
Prefix:MS
First Name:JEAN
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:140 CHRISTIANSBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:FLOYD
Mailing Address - State:VA
Mailing Address - Zip Code:24091-3742
Mailing Address - Country:US
Mailing Address - Phone:540-745-9290
Mailing Address - Fax:540-745-9294
Practice Address - Street 1:140 CHRISTIANSBURG PIKE
Practice Address - Street 2:
Practice Address - City:FLOYD
Practice Address - State:VA
Practice Address - Zip Code:24091-3742
Practice Address - Country:US
Practice Address - Phone:540-745-9290
Practice Address - Fax:540-745-9294
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0024101703363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1194908491Medicaid
VAS49224Medicare UPIN