Provider Demographics
NPI:1649771072
Name:BLACK, JODI
Entity Type:Individual
Prefix:
First Name:JODI
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14710 STATE HIGHWAY 154 E
Mailing Address - Street 2:
Mailing Address - City:DIANA
Mailing Address - State:TX
Mailing Address - Zip Code:75640-3801
Mailing Address - Country:US
Mailing Address - Phone:903-932-1871
Mailing Address - Fax:
Practice Address - Street 1:120 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:TX
Practice Address - Zip Code:75657-1934
Practice Address - Country:US
Practice Address - Phone:903-665-6653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226279164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Multi-Specialty