Provider Demographics
NPI:1710347943
Name:BLACK, JENNIFER LEIGH (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LEIGH
Last Name:BLACK
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 JACK FOSTER DR
Mailing Address - Street 2:
Mailing Address - City:SHENANDOAH
Mailing Address - State:IA
Mailing Address - Zip Code:51601-4586
Mailing Address - Country:US
Mailing Address - Phone:712-246-7400
Mailing Address - Fax:712-246-7319
Practice Address - Street 1:1 JACK FOSTER DR
Practice Address - Street 2:
Practice Address - City:SHENANDOAH
Practice Address - State:IA
Practice Address - Zip Code:51601-4586
Practice Address - Country:US
Practice Address - Phone:712-246-7400
Practice Address - Fax:712-246-7319
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA149915363LF0000X
IAG166344363LP0808X
AK109970363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health