Provider Demographics
NPI:1053980631
Name:BLACK, JENNIFER (IBCLC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:829 W MLK BLVD STE 256
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603-3309
Mailing Address - Country:US
Mailing Address - Phone:803-807-7810
Mailing Address - Fax:
Practice Address - Street 1:829 W MLK BLVD STE 256
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-3309
Practice Address - Country:US
Practice Address - Phone:803-807-3454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-18
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X, 172V00000X, 174H00000X
L-72574174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RNGroup - Multi-Specialty
No171400000XOther Service ProvidersHealth & Wellness Coach
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty
No174H00000XOther Service ProvidersHealth Educator