Healthcare Provider Details

I. General information

NPI: 1205677291
Provider Name (Legal Business Name): AALIYAH JORDAN BLACK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 LIBERTY DR
HEBRON CT
06248
US

IV. Provider business mailing address

41 MASSABESIC DR
AUBURN NH
03032-3167
US

V. Phone/Fax

Practice location:
  • Phone: 860-228-9300
  • Fax: 860-228-4703
Mailing address:
  • Phone: 860-228-9300
  • Fax: 860-228-4703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: