Provider Demographics
NPI:1912370354
Name:BLACK, JENNIFER (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 INDEPENDENCE PKWY STE 115
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-5209
Mailing Address - Country:US
Mailing Address - Phone:757-312-8002
Mailing Address - Fax:757-312-9299
Practice Address - Street 1:609 INDEPENDENCE PKWY STE 115
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-5209
Practice Address - Country:US
Practice Address - Phone:757-312-8002
Practice Address - Fax:757-312-9299
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2015-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040091581041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical