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General NPI Number Information
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NPI Number | 1063330926
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Entity Type | Individual
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Provider Name | JENNA BLACK
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Gender | Female
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Dates
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Enumeration Date | 07/08/2026
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Last Update Date | 07/08/2026
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Provider Practice Location Address
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Address Line | 1305 ESCALANTE DR STE 206
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City | DURANGO
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State | CO
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Zip | 81303-8932
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Country | US
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Telephone | 719-310-6329
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Fax |
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Provider Business Mailing Address
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Address Line | 1764 PINE VALLEY RD
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City | BAYFIELD
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State | CO
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Zip | 81122-9205
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 1002139-NP
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License Number State | CO
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