Healthcare Provider Details

I. General information

NPI: 1063330926
Provider Name (Legal Business Name): JENNA BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 ESCALANTE DR STE 206
DURANGO CO
81303-8932
US

IV. Provider business mailing address

1764 PINE VALLEY RD
BAYFIELD CO
81122-9205
US

V. Phone/Fax

Practice location:
  • Phone: 719-310-6329
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1002139-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: