Provider Demographics
NPI:1316253164
Name:AVERY, JENNIFER GOOCH (PT)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GOOCH
Last Name:AVERY
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 DOANE RD
Mailing Address - Street 2:
Mailing Address - City:HARWICH PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02646-1529
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:65 OLD COLONY WAY
Practice Address - Street 2:ORLEANS MARKETPLACE
Practice Address - City:ORLEANS
Practice Address - State:MA
Practice Address - Zip Code:02653-3213
Practice Address - Country:US
Practice Address - Phone:508-240-7203
Practice Address - Fax:508-240-1761
Is Sole Proprietor?:No
Enumeration Date:2010-08-30
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10753225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist