Provider Demographics
NPI:1689172769
Name:BLACK, JENNIFER LEE (APN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEE
Last Name:BLACK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 OSIGIAN BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31088-8008
Mailing Address - Country:US
Mailing Address - Phone:478-971-1099
Mailing Address - Fax:478-971-1098
Practice Address - Street 1:500 OSIGIAN BLVD STE 300
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31088-8008
Practice Address - Country:US
Practice Address - Phone:478-971-1099
Practice Address - Fax:478-971-1098
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN089820363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner