Black, Jackie Evans

Black, Jackie Evans is an individual health care provider with primary practice located at 151 S University Ave # 1900 , Provo UT 84601-4427. She recently has only one registered license in Nursing Service Providers / Community Health, which is considered as her primary health care specialty. Black, Jackie Evans can be contacted via phone (801) 851-7026.

Contact Information

Primary practice address
151 S University Ave # 1900 Provo UT 84601-4427
Phone: (801) 851-7026
Fax: (801) 343-8725
Website:
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Health care specialties

SpecialtyCodeLicense #State
Nursing Service Providers / Community Health 163WC1500X 218040-3102 Utah

Profile Details

NPI number 1629144308
LBN Legal business name Black, Jackie Evans
Credentials Registered Nurse (RN)
Entity Individual
Sole proprietor 1 No
Enumeration date Nov 27th, 2006
Last updated Jul 9th, 2007 - about 17 years ago

1 A sole proprietor/sole proprietorship is an individual, and in that capacity, is qualified for a solitary NPI number. The sole proprietor have to apply for the NPI number using his or her own particular Social Security Number (SSN), instead of Employer Identification Number (EIN) regardless of whether he/she has an EIN.

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Identifiers

StateTypeNumberIssuer
All States NPI 1629144308 NPPES
Utah MEDICAID 998877660009
Utah Other QM0000039389
Utah Other 55102
Utah Other 103003506102
Utah MEDICAID PR00489
Utah Other 73-00012

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