MEDICARE: JENNAH BLACK LAC., DIPL. OM, MSOM

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	171100000X	Acupuncturist	198.001477	IL
2	171100000X	Acupuncturist	ACU.0002749	CO

General Provider Information

NPI Number	:	1821640442
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNAH BLACK LAC., DIPL. OM, MSOM

Provider Business Mailing Address
First Line	:	PO BOX 26661
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80936-6661
Country	:	US
Telephone Number	:	720-933-6633
Fax Number	:

Provider Business Practice Location Address
First Line	:	3613 JEANNINE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-8002
Country	:	US
Telephone Number	:	720-933-6633
Fax Number	:

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

Provider Enumeration Date	:	07/13/2019
Last Update Date	:	06/16/2022

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