Provider Demographics
NPI:1881244374
Name:BLACK, JESSICA G (LPTA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:G
Last Name:BLACK
Suffix:
Gender:F
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8837 CHESTER FOREST LN
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23237-2655
Mailing Address - Country:US
Mailing Address - Phone:804-338-7667
Mailing Address - Fax:
Practice Address - Street 1:10300 COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23832
Practice Address - Country:US
Practice Address - Phone:804-203-1991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306603665208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation