Healthcare Provider Details

I. General information

NPI: 1366810905
Provider Name (Legal Business Name): JAZMIN BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2015
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 HOPKINS BAYVIEW CIR
BALTIMORE MD
21224-6821
US

IV. Provider business mailing address

4701 N CHARLES ST
BALTIMORE MD
21210-2404
US

V. Phone/Fax

Practice location:
  • Phone: 410-550-0925
  • Fax:
Mailing address:
  • Phone: 410-532-5063
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24145
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License NumberPH236263
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: