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General NPI Number Information
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NPI Number | 1104678440
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Entity Type | Individual
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Provider Name | JESSICA MINN BLACK LCPC
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Gender | Female
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Dates
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Enumeration Date | 04/02/2024
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Last Update Date | 11/01/2024
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Provider Practice Location Address
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Address Line | 6804 US HIGHWAY 212
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City | RED LODGE
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State | MT
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Zip | 59068-9310
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Country | US
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Telephone | 406-213-6618
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 103
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City | RED LODGE
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State | MT
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Zip | 59068-0103
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Country | US
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Telephone | 406-213-6618
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | BBH-LCPC-LIC-70494
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License Number State | MT
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