Provider Demographics
NPI:1770346785
Name:BLACK, JALISSA NICOLE (OTD, OTR)
Entity type:Individual
Prefix:
First Name:JALISSA
Middle Name:NICOLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:OTD, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3256 N VALDOSTA RD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1778
Mailing Address - Country:US
Mailing Address - Phone:229-560-6944
Mailing Address - Fax:888-450-0379
Practice Address - Street 1:3256 N VALDOSTA RD
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1778
Practice Address - Country:US
Practice Address - Phone:229-560-6944
Practice Address - Fax:888-450-0379
Is Sole Proprietor?:No
Enumeration Date:2024-02-01
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT009030225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist