Provider Demographics
NPI:1306930086
Name:AVERY, JACK D (CCC/SLP)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:AVERY
Suffix:
Gender:M
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MINNEAPOLIS VAMC
Mailing Address - Street 2:1 VETERANS DRIVE
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417
Mailing Address - Country:US
Mailing Address - Phone:612-467-5289
Mailing Address - Fax:612-467-2144
Practice Address - Street 1:MINNEAPOLIS VAMC
Practice Address - Street 2:1 VETERANS DRIVE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417
Practice Address - Country:US
Practice Address - Phone:612-467-5289
Practice Address - Fax:612-467-2144
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5938235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5938OtherSPEECH PATHOLOGY LICENSE
MN01103833OtherASHA I.D. NUMBER