Provider Demographics
NPI:1770349755
Name:BLACK, JENNIFER
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
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 1:615 2ND ST APT 3
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-4077
Mailing Address - Country:US
Mailing Address - Phone:419-344-0772
Mailing Address - Fax:
Practice Address - Street 1:1003 KETCHAM AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-2164
Practice Address - Country:US
Practice Address - Phone:419-344-0772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No172A00000XOther Service ProvidersDriver
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No376J00000XNursing Service Related ProvidersHomemaker