Provider Demographics
NPI:1568588531
Name:BLACK, JEFFERY TODD (COTA)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:TODD
Last Name:BLACK
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 OAKMONT RD STE B
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1130
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:302 CEDAR RIDGE RD
Practice Address - Street 2:
Practice Address - City:SISSONVILLE
Practice Address - State:WV
Practice Address - Zip Code:25320-9502
Practice Address - Country:US
Practice Address - Phone:304-984-0046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVC#1399224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant