Provider Demographics
NPI:1316459084
Name:BLACK, JOHNATHAN SHANE
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:SHANE
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7120 AIRPORT BLVD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36608-4502
Mailing Address - Country:US
Mailing Address - Phone:251-345-3303
Mailing Address - Fax:
Practice Address - Street 1:7120 AIRPORT BLVD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-4502
Practice Address - Country:US
Practice Address - Phone:251-345-3303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2017-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3106101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health