Provider Demographics
NPI:1174607576
Name:BLACK, JENNIFER K (NP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:K
Other - Last Name:LOWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 19420
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9420
Mailing Address - Country:US
Mailing Address - Phone:217-788-0706
Mailing Address - Fax:217-525-2535
Practice Address - Street 1:619 E MASON ST
Practice Address - Street 2:SUITE 4P57
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-1034
Practice Address - Country:US
Practice Address - Phone:217-788-0706
Practice Address - Fax:217-525-2535
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209002373207RI0011X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL596500OtherRAILROAD
IL596500OtherRAILROAD
IL$$$$$$$$$001Medicaid
ILK23477Medicare ID - Type Unspecified
ILP11978Medicare UPIN