Individual
JODI BLACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
120 N WALNUT ST, JEFFERSON, TX 75657-1934
(903) 665-6653
Mailing address
14710 STATE HIGHWAY 154 E, DIANA, TX 75640-3801
(903) 932-1871
Taxonomy
Speciality
Code
Description
License number
State
164X00000X
Licensed Vocational Nurse
Primary
226279
TX
Other
Enumeration date
02/21/2018
Last updated
02/21/2018
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