Provider Demographics
NPI:1194334805
Name:BLACK, JACYLIN
Entity type:Individual
Prefix:
First Name:JACYLIN
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16804 FALCON SOUND DR
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:TX
Mailing Address - Zip Code:77356-8386
Mailing Address - Country:US
Mailing Address - Phone:281-645-9999
Mailing Address - Fax:
Practice Address - Street 1:7619 FRIESIAN MEADOW LN
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-6745
Practice Address - Country:US
Practice Address - Phone:281-917-1108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health