Provider Demographics
NPI:1457034191
Name:BLACK, JEREMY TAYLOR I
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:TAYLOR
Last Name:BLACK
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6517 CEDAR BEND CT
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-5333
Mailing Address - Country:US
Mailing Address - Phone:801-842-1517
Mailing Address - Fax:
Practice Address - Street 1:6517 CEDAR BEND CT
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-5333
Practice Address - Country:US
Practice Address - Phone:801-842-1517
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program