MEDICARE: KENYATTA BLACK-JACOBS M.A., LPC

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	101YP2500X	Professional Counselor	66056	TX

General Provider Information

NPI Number	:	1902188444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYATTA BLACK-JACOBS M.A., LPC

Provider Business Mailing Address
First Line	:	607 SOTOGRANDE ST
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75051-4456
Country	:	US
Telephone Number	:	214-298-2780
Fax Number	:

Provider Business Practice Location Address
First Line	:	3939 W GREEN OAKS BLVD STE 214
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016-2793
Country	:	US
Telephone Number	:	214-298-2780
Fax Number	:	214-380-4965

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

Provider Enumeration Date	:	09/11/2011
Last Update Date	:	05/10/2024

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