Provider Demographics
NPI:1497070510
Name:BLACK, JEANETTE MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEANETTE
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2285 CORPORATE CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-360-2763
Mailing Address - Fax:949-783-2880
Practice Address - Street 1:9201 W SUNSET BLVD
Practice Address - Street 2:SUITE 602
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90069-3701
Practice Address - Country:US
Practice Address - Phone:310-246-0495
Practice Address - Fax:310-246-0496
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-31
Last Update Date:2017-06-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA136731207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology