Provider Demographics
NPI:1467079111
Name:BLACK, JENNIFER ROSE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 MAGNOLIA FARMS DR
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-1638
Mailing Address - Country:US
Mailing Address - Phone:615-294-2314
Mailing Address - Fax:
Practice Address - Street 1:1703 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3186
Practice Address - Country:US
Practice Address - Phone:615-444-3576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-29
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN44141183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist