Provider Demographics
NPI:1053772632
Name:AVERY, JENNIFER (LCMHC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:AVERY
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4313 MURDOCK CT
Mailing Address - Street 2:
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28470-4310
Mailing Address - Country:US
Mailing Address - Phone:910-880-0154
Mailing Address - Fax:
Practice Address - Street 1:5013 WRIGHTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-7045
Practice Address - Country:US
Practice Address - Phone:910-796-6868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12178101YP2500X
NC12178101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional