Provider Demographics
NPI:1477950749
Name:BLACK, JILLIAN (MS, EDS)
Entity Type:Individual
Prefix:MRS
First Name:JILLIAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS, EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6656 FOUNTAINS BLVD UNIT 7
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:45069-6128
Mailing Address - Country:US
Mailing Address - Phone:330-933-2766
Mailing Address - Fax:
Practice Address - Street 1:755 WESTERN ROW ROAD
Practice Address - Street 2:WESTERN ROW ELEMENTARY
Practice Address - City:MASON
Practice Address - State:OH
Practice Address - Zip Code:45040
Practice Address - Country:US
Practice Address - Phone:513-398-5821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-02
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21027332103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool