Provider Demographics
NPI:1851894547
Name:BLACK, JESSICA J (PHD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:J
Last Name:BLACK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:JAN
Other - Last Name:BLACK-LEIGEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:225 HUMPHREY RD STE 4
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601-4571
Mailing Address - Country:US
Mailing Address - Phone:724-832-9096
Mailing Address - Fax:724-832-2249
Practice Address - Street 1:225 HUMPHREY RD STE 4
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-4571
Practice Address - Country:US
Practice Address - Phone:724-832-9096
Practice Address - Fax:724-832-2249
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS017812103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAPS017812OtherCOMMONWEALTH OF PENNSYLVANIA DEPT. OF STATE