MEDICARE: JENNIFER A. BLACK M.A. 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	SP1713	ME

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982737698
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER A. BLACK M.A. CCC-SLP

Provider Business Mailing Address
First Line	:	16 MADISON AVE
Second Line	:
City	:	OXFORD
State	:	ME
Zip	:	04270-3579
Country	:	US
Telephone Number	:	207-743-7035
Fax Number	:	207-743-2970

Provider Business Practice Location Address
First Line	:	24 FALCON DR
Second Line	:
City	:	AUBURN
State	:	ME
Zip	:	04210-4384
Country	:	US
Telephone Number	:	207-782-5437
Fax Number	:	207-753-0105

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

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	06/11/2009

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Directions to “ JENNIFER A. BLACK M.A. CCC-SLP” Practice Location

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