Provider Demographics
NPI:1659930618
Name:AVERILL, JACOB (LCSWA, LCAS)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:AVERILL
Suffix:
Gender:M
Credentials:LCSWA, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-6431
Mailing Address - Country:US
Mailing Address - Phone:910-399-3755
Mailing Address - Fax:910-202-9966
Practice Address - Street 1:309 PROGRESS DRIVE
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425-5001
Practice Address - Country:US
Practice Address - Phone:910-259-0668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC25590101YA0400X
1041C0700X
NCP0136611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)