Provider Demographics
NPI:1124778188
Name:AVERY, JAYVONNA
Entity type:Individual
Prefix:
First Name:JAYVONNA
Middle Name:
Last Name:AVERY
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 1:2720 HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-8007
Mailing Address - Country:US
Mailing Address - Phone:409-658-2149
Mailing Address - Fax:
Practice Address - Street 1:655 S 23RD ST TRLR 69
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77707-3836
Practice Address - Country:US
Practice Address - Phone:409-658-2139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16719101YP1600X, 101YP2500X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional