Healthcare Provider Details

I. General information

NPI: 1467271973
Provider Name (Legal Business Name): JENNIFER BLACK ED.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5334 HORNET AVE
BEECH GROVE IN
46107-2306
US

IV. Provider business mailing address

5334 HORNET AVE
BEECH GROVE IN
46107-2306
US

V. Phone/Fax

Practice location:
  • Phone: 317-780-5050
  • Fax:
Mailing address:
  • Phone: 317-780-5050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1567410
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: