Provider Demographics
NPI:1316926611
Name:POWELL, JESS AVERETTE III (MD)
Entity type:Individual
Prefix:DR
First Name:JESS
Middle Name:AVERETTE
Last Name:POWELL
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 N LAFAYETTE ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-4444
Mailing Address - Country:US
Mailing Address - Phone:704-482-3880
Mailing Address - Fax:704-487-0294
Practice Address - Street 1:222 N LAFAYETTE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4444
Practice Address - Country:US
Practice Address - Phone:704-482-3880
Practice Address - Fax:704-487-0294
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC22163174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8968644Medicaid
NC22163OtherNC MEDICAL LICENSE
NC68644OtherNC BLUE CROSS BLUE SHIELD
SC293590Medicaid
SC293590Medicaid
212632Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE
SC293590Medicaid
NC8968644Medicaid