Healthcare Provider Details

I. General information

NPI: 1053980631
Provider Name (Legal Business Name): JENNIFER BLACK IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 02/06/2024
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 W MLK BLVD STE 256
TAMPA FL
33603-3309
US

IV. Provider business mailing address

829 W MLK BLVD STE 256
TAMPA FL
33603-3309
US

V. Phone/Fax

Practice location:
  • Phone: 803-807-3454
  • Fax:
Mailing address:
  • Phone: 803-807-7810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-72574
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: