MEDICARE: JESSICA BLACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1235089640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA BLACK

Provider Business Mailing Address
First Line	:	1927 KATE LN
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29575-5319
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1927 KATE LN
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29575-5319
Country	:	US
Telephone Number	:	843-283-1688
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/03/2026
Last Update Date	:	02/03/2026

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Directions to “ JESSICA BLACK ” Practice Location

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