MEDICARE: JENNIFER A 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
1	225700000X	Massage Therapist	7301	NM

General Provider Information

NPI Number	:	1376872754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER A BLACK

Provider Business Mailing Address
First Line	:	3809 ATRISCO DR NW
Second Line	:	SUITE C
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-4902
Country	:	US
Telephone Number	:	505-615-3487
Fax Number	:	505-352-8966

Provider Business Practice Location Address
First Line	:	3809 ATRISCO DR NW
Second Line	:	SUITE C
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87120-4902
Country	:	US
Telephone Number	:	505-615-3487
Fax Number	:	505-352-8966

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2009
Last Update Date	:	12/16/2014

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