Provider Demographics
NPI:1477600070
Name:AVINGTON, JERRY L
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:L
Last Name:AVINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4648 HODGE RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38109-5963
Mailing Address - Country:US
Mailing Address - Phone:901-785-2119
Mailing Address - Fax:
Practice Address - Street 1:1087 ALICE AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38106-6543
Practice Address - Country:US
Practice Address - Phone:901-259-1920
Practice Address - Fax:901-259-1922
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health