Provider Demographics
NPI:1588553317
Name:BLACK, JENNA BETH (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:JENNA
Middle Name:BETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8108B POINT SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-6743
Mailing Address - Country:US
Mailing Address - Phone:256-453-4990
Mailing Address - Fax:
Practice Address - Street 1:8108B POINT SHERMAN DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-6743
Practice Address - Country:US
Practice Address - Phone:256-453-4990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-27
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK219076235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist