Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 2251N0400X | Physical Therapist - Neurology | 070005649 | IL |
NPI | 1215252036 |
---|---|
Provider Name | Mrs. Jonella Renee Black |
First Address | Evanston, IL 60202 |
Second Address | Evanston, IL 60201-1777 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/04/2010 |
Last Update Date | 05/04/2010 |