Provider Demographics
NPI:1467271973
Name:BLACK, JENNIFER (EDS)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5334 HORNET AVE
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107-2306
Mailing Address - Country:US
Mailing Address - Phone:317-780-5050
Mailing Address - Fax:
Practice Address - Street 1:5334 HORNET AVE
Practice Address - Street 2:
Practice Address - City:BEECH GROVE
Practice Address - State:IN
Practice Address - Zip Code:46107-2306
Practice Address - Country:US
Practice Address - Phone:317-780-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1567410103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool