Provider Demographics
NPI:1891195749
Name:BLACK, JENNIFER (MS, ALC)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MS, ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 EAST ANDREWS AVE SUTIE D
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360
Mailing Address - Country:US
Mailing Address - Phone:334-797-5880
Mailing Address - Fax:334-460-9758
Practice Address - Street 1:1518 ANDREWS AVE STE D
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-3716
Practice Address - Country:US
Practice Address - Phone:334-797-5880
Practice Address - Fax:334-460-9758
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALC2121A101Y00000X
AL3890101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor