1417938416 NPI number — MS. JEAN MARIE BLACK N.P.

Employer Identification Number (EIN)	:
Provider Organization Name (Legal Business Name)	:
Provider Last Name (Legal Name)	:	BLACK
Provider First Name	:	JEAN
Provider Middle Name	:	MARIE
Provider Name Prefix Text	:	MS.
Provider Name Suffix Text	:
Provider Credential Text	:	N.P.
Provider Gender Code	:	F

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Provider Other First Name	:
Provider Other Middle Name	:
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Provider Other Name Suffix Text	:
Provider Other Credential Text	:
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NPI Number	:	1417938416
Entity Type Code	:	Individual
Replacement NPI	:
Last Update Date	:	07/08/2007
NPI Deactivation Reason Code	:
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Provider First Line Business Mailing Address	:	9104 FLOYD HWY N
Provider Second Line Business Mailing Address	:
Provider Business Mailing Address City Name	:	COPPER HILL
Provider Business Mailing Address State Name	:	VA
Provider Business Mailing Address Postal Code	:	240792114
Provider Business Mailing Address Country Code	:	US
Provider Business Mailing Address Telephone Number	:	5409299095
Provider Business Mailing Address Fax Number	:	5409299003

Provider First Line Business Practice Location Address	:	9104 FLOYD HWY N
Provider Second Line Business Practice Location Address	:
Provider Business Practice Location Address City Name	:	COPPER HILL
Provider Business Practice Location Address State Name	:	VA
Provider Business Practice Location Address Postal Code	:	240792114
Provider Business Practice Location Address Country Code	:	US
Provider Business Practice Location Address Telephone Number	:	5409299095
Provider Business Practice Location Address Fax Number	:	5409299003
Provider Enumeration Date	:	11/08/2005

Authorized Official Last Name	:
Authorized Official First Name	:
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• Taxonomy code: 363LF0000X , with the licence number:  0024101703 , registered in the state of VA .

• Identifier: S49224 , issued by the state of ( VA ) . This identifiers is of the category "".