Provider Demographics
NPI:1285127530
Name:BLACK, JAYLEA
Entity type:Individual
Prefix:
First Name:JAYLEA
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 1:4320 VINE STREET
Mailing Address - Street 2:UNIT 80 - PMB 191
Mailing Address - City:HAYS
Mailing Address - State:KS
Mailing Address - Zip Code:67601-3551
Mailing Address - Country:US
Mailing Address - Phone:785-734-0292
Mailing Address - Fax:
Practice Address - Street 1:4320 VINE STREET
Practice Address - Street 2:UNIT 80 - PMB 191
Practice Address - City:HAYS
Practice Address - State:KS
Practice Address - Zip Code:67601-3551
Practice Address - Country:US
Practice Address - Phone:785-734-0292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-12
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS752101YA0400X
COCSW.099275681041C0700X
KS053191041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)