Provider Demographics
NPI:1972716314
Name:BLACK, WILLIAM JESSE (LICSW, LADC, BCD)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JESSE
Last Name:BLACK
Suffix:
Gender:M
Credentials:LICSW, LADC, BCD
Other - Prefix:MR
Other - First Name:SKIP
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:271 CYPRESS DRIVE
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:271 CYPRESS DRIVE
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311
Practice Address - Country:US
Practice Address - Phone:507-732-4136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN44761041C0700X
MN300555101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1972716314Medicaid