Provider Demographics
NPI:1649022344
Name:BLACK, JONAS (DOO)
Entity type:Individual
Prefix:
First Name:JONAS
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:DOO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7611 BREEZY POINT LN APT 207
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-6794
Mailing Address - Country:US
Mailing Address - Phone:919-612-3740
Mailing Address - Fax:
Practice Address - Street 1:2100 STANTONSBURG RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2818
Practice Address - Country:US
Practice Address - Phone:252-847-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-04
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program