Provider Demographics
NPI:1962586370
Name:AVERY, JACK H (RT (R) (MRI)(QM)(CT))
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:H
Last Name:AVERY
Suffix:
Gender:M
Credentials:RT (R) (MRI)(QM)(CT)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5179
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59604-5179
Mailing Address - Country:US
Mailing Address - Phone:406-449-3750
Mailing Address - Fax:406-449-3752
Practice Address - Street 1:3510 PTARMIGAN LN
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-0553
Practice Address - Country:US
Practice Address - Phone:406-449-3750
Practice Address - Fax:406-449-3752
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MT1019247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0760123Medicaid