Basic Information
| Provider Information | |||||||||
| NPI: | 1235269507 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW, LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHAW | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW, ASW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3142 VISTA WAY STE 205 | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920563628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607581480 | ||||||||
| FaxNumber: | 7604359472 | ||||||||
| Practice Location | |||||||||
| Address1: | 3142 VISTA WAY STE 205 | ||||||||
| Address2: | |||||||||
| City: | OCEANSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920563628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607581480 | ||||||||
| FaxNumber: | 7604359472 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 03/15/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LCS 25959 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.