Provider Demographics
NPI:1710347943
Name:BLACK, JENNIFER LEIGH (APRN)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1219 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:IA
Mailing Address - Zip Code:51640-1300
Mailing Address - Country:US
Mailing Address - Phone:907-631-4933
Mailing Address - Fax:907-631-5933
Practice Address - Street 1:711 S VINE ST
Practice Address - Street 2:
Practice Address - City:GLENWOOD
Practice Address - State:IA
Practice Address - Zip Code:51534-1927
Practice Address - Country:US
Practice Address - Phone:712-525-1397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA149915363LF0000X
AK109970363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily