Provider Demographics
NPI:1033666714
Name:BLACK, JENNIFER (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11046 NEW GEORGES CREEK RD SW
Mailing Address - Street 2:
Mailing Address - City:FROSTBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21532-1448
Mailing Address - Country:US
Mailing Address - Phone:240-284-2600
Mailing Address - Fax:
Practice Address - Street 1:11046 NEW GEORGES CREEK RD SW
Practice Address - Street 2:
Practice Address - City:FROSTBURG
Practice Address - State:MD
Practice Address - Zip Code:21532-1448
Practice Address - Country:US
Practice Address - Phone:240-284-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-09
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08012225XP0200X, 225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics