Provider Demographics
NPI:1982737698
Name:BLACK, JENNIFER A (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:BLACK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:PATRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:16 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04270-3579
Mailing Address - Country:US
Mailing Address - Phone:207-743-7035
Mailing Address - Fax:207-743-2970
Practice Address - Street 1:24 FALCON DR
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-4384
Practice Address - Country:US
Practice Address - Phone:207-782-5437
Practice Address - Fax:207-753-0105
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2009-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1713235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME26179099Medicaid