Provider Demographics
NPI:1689370744
Name:BLACK, JENNIFER NICOLE (DPT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:NICOLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:NICOLE
Other - Last Name:GEHRIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:625 KENMOOR AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2395
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:
Practice Address - Street 1:740 W FIRE TOWER RD STE 113
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-8477
Practice Address - Country:US
Practice Address - Phone:252-329-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist