Provider Demographics
NPI:1154975001
Name:MCAVOY, JACOB (DMSC, PA-C)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MCAVOY
Suffix:
Gender:M
Credentials:DMSC, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:671 SW MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON
Mailing Address - State:OR
Mailing Address - Zip Code:97496-6571
Mailing Address - Country:US
Mailing Address - Phone:541-492-4550
Mailing Address - Fax:
Practice Address - Street 1:1077 GATEWAY LOOP
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1114
Practice Address - Country:US
Practice Address - Phone:541-485-6478
Practice Address - Fax:541-868-9606
Is Sole Proprietor?:No
Enumeration Date:2019-07-30
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OR363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant