Healthcare Provider Details

I. General information

NPI: 1649771072
Provider Name (Legal Business Name): JODI BLACK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2018
Last Update Date: 02/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N WALNUT ST
JEFFERSON TX
75657-1934
US

IV. Provider business mailing address

14710 STATE HIGHWAY 154 E
DIANA TX
75640-3801
US

V. Phone/Fax

Practice location:
  • Phone: 903-665-6653
  • Fax:
Mailing address:
  • Phone: 903-932-1871
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number226279
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: