Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003269838 |
---|---|
Provider Name | Mrs. Jennifer Black |
First Address | Tulsa, OK 74120-4429 |
Second Address | Tulsa, OK 74114-3300 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2016 |
Last Update Date | 18/07/2016 |