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General NPI Number Information
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NPI Number | 1063757268
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Entity Type | Individual
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Provider Name | JILL MICHELE BLACK LMFT
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Gender | Female
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Dates
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Enumeration Date | 11/29/2012
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Last Update Date | 08/04/2020
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Provider Practice Location Address
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Address Line | 30101 AGOURA CT LOBBY 3 SUITE 150
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City | AGOURA HILLS
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State | CA
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Zip | 91301-5806
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Country | US
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Telephone | 805-657-2511
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Fax | 805-856-2219
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Provider Business Mailing Address
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Address Line | 30101 AGOURA CT LOBBY 3 SUITE 150
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City | AGOURA HILLS
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State | CA
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Zip | 91301-5806
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Country | US
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Telephone | 805-657-2511
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Fax | 805-856-2219
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 52229
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License Number State | CA
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