Healthcare Provider Details

I. General information

NPI: 1063908051
Provider Name (Legal Business Name): JARRET AVERY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2018
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

548 SW 13TH ST
BEND OR
97702-3184
US

IV. Provider business mailing address

1333 NW 9TH ST
PRINEVILLE OR
97754-1482
US

V. Phone/Fax

Practice location:
  • Phone: 541-388-8116
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier33
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: