Provider Demographics
NPI:1215252036
Name:BLACK, JONELLA RENEE (PT)
Entity type:Individual
Prefix:MRS
First Name:JONELLA
Middle Name:RENEE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 MADISON STREET
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202
Mailing Address - Country:US
Mailing Address - Phone:847-864-5740
Mailing Address - Fax:
Practice Address - Street 1:1000 CENTRAL ST
Practice Address - Street 2:SUITE 101
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-1777
Practice Address - Country:US
Practice Address - Phone:847-570-1260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-05
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0700056492251N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251N0400XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistNeurology