Provider Demographics
NPI:1316996671
Name:JACK, AVANELLE V (MD)
Entity type:Individual
Prefix:DR
First Name:AVANELLE
Middle Name:V
Last Name:JACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AVANELLE
Other - Middle Name:V
Other - Last Name:JACK-JACKSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:208 SCRANTON CONNECTOR
Mailing Address - Street 2:SUITE 117
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525
Mailing Address - Country:US
Mailing Address - Phone:912-264-5961
Mailing Address - Fax:912-262-9499
Practice Address - Street 1:208 SCRANTON CONNECTOR STE 117
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31525-0560
Practice Address - Country:US
Practice Address - Phone:912-264-5961
Practice Address - Fax:912-262-9499
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.022645207RN0300X
GA78666207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1491501Medicaid
LA4A574F669Medicare PIN
LA1491501Medicaid
LA4A574Medicare PIN
H45588Medicare UPIN