Provider Demographics
NPI:1194763326
Name:BLACK, JENNIFER MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 N EL CAMINO REAL STE A200
Mailing Address - Street 2:
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1350
Mailing Address - Country:US
Mailing Address - Phone:858-766-6007
Mailing Address - Fax:858-900-9800
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:760-631-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43773-020207R00000X, 208M00000X
CAA84075207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34469600Medicaid
WI741501990Medicare PIN