MEDICARE: JENNIFER BLACK MA CCC SLP

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	235Z00000X	Speech-Language Pathologist	SA 7436	FL

General Provider Information

NPI Number	:	1801120662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER BLACK MA CCC SLP

Provider Business Mailing Address
First Line	:	3778 HANOVER ST
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8503
Country	:	US
Telephone Number	:	239-939-6993
Fax Number	:

Provider Business Practice Location Address
First Line	:	3778 HANOVER ST
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-8503
Country	:	US
Telephone Number	:	239-939-6993
Fax Number	:

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

Provider Enumeration Date	:	09/28/2009
Last Update Date	:	09/28/2009

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Directions to “ JENNIFER BLACK MA CCC SLP” Practice Location

Language	Start Address	Practice Location

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