MEDICARE: MS. JENNY BLACK RN

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	163W00000X	Registered Nurse	699101	TX

General Provider Information

NPI Number	:	1790574655
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JENNY BLACK RN

Provider Business Mailing Address
First Line	:	2200 COLLEGE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1950
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 COLLEGE AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76110-1950
Country	:	US
Telephone Number	:	512-203-6416
Fax Number	:

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

Provider Enumeration Date	:	05/06/2025
Last Update Date	:	05/06/2025

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