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NPI Code Detail

MEDICARE: MRS. JESSICA ANNE BLACK

MEDICARE: MRS. JESSICA ANNE BLACK
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225X00000XOccupational Therapist5296NC
2225XH1200XHand Occupational Therapist5296NC
3225X00000XOccupational Therapist31005917AIN

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1555850076OTHERINMEDICARE PTAN
2P00263219OTHERRAILROAD MEDICARE

General Provider Information

NPI Number : 1336102607
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JESSICA ANNE BLACK
Provider Business Mailing Address
First Line : 790 REMINGTON BLVD
Second Line :
City : BOLINGBROOK
State : IL
Zip : 60440-4909
Country : US
Telephone Number : 630-296-2223
Fax Number : 630-759-9510
Provider Business Practice Location Address
First Line : 9302 N MERIDIAN ST STE 190
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46260-1818
Country : US
Telephone Number : 317-843-1270
Fax Number : 317-843-4174
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/08/2006
Last Update Date : 04/07/2016

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Directions to “ MRS. JESSICA ANNE BLACK ” Practice Location

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