Provider Demographics
NPI:1598125577
Name:BLACK, JEANNE (RN BSN)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 OLD MAIN DRIVE
Mailing Address - Street 2:RESA 4
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651
Mailing Address - Country:US
Mailing Address - Phone:304-872-6440
Mailing Address - Fax:304-872-6442
Practice Address - Street 1:111 FAYETTE AVENUE
Practice Address - Street 2:FAYETTE COUNTY SCHOOLS
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840
Practice Address - Country:US
Practice Address - Phone:304-574-1176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV72617163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool