Healthcare Provider Details

I. General information

NPI: 1750333951
Provider Name (Legal Business Name): JENNA E BLACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

2520 INDEPENDENCE BLVD STE 200
WILMINGTON NC
28412-2482
US

V. Phone/Fax

Practice location:
  • Phone: 910-442-1100
  • Fax:
Mailing address:
  • Phone: 910-442-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number400640
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: