Provider Demographics
NPI:1740903681
Name:BLACK, JESSIE (NP)
Entity type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 MASTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICKASAW
Mailing Address - State:AL
Mailing Address - Zip Code:36611-1618
Mailing Address - Country:US
Mailing Address - Phone:251-689-6356
Mailing Address - Fax:
Practice Address - Street 1:608 MASTERSON AVE
Practice Address - Street 2:
Practice Address - City:CHICKASAW
Practice Address - State:AL
Practice Address - Zip Code:36611-1618
Practice Address - Country:US
Practice Address - Phone:251-689-6356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-095422363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily