Provider Demographics
NPI:1336525815
Name:BLACK, JENNIFER (MD, PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 EDEN WAY N
Mailing Address - Street 2:419.
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-3355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER SAN DIEGO 34800 BOB WILSON DRIVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-3824
Practice Address - Country:US
Practice Address - Phone:757-204-5715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0202214315183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program