Provider Demographics
NPI:1992146260
Name:AVERY, JAKE DEWAYNE
Entity type:Individual
Prefix:MR
First Name:JAKE
Middle Name:DEWAYNE
Last Name:AVERY
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 1:18544 S 344TH WEST AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOW
Mailing Address - State:OK
Mailing Address - Zip Code:74010-2173
Mailing Address - Country:US
Mailing Address - Phone:918-671-0758
Mailing Address - Fax:
Practice Address - Street 1:6202 S LEWIS AVE STE M
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1064
Practice Address - Country:US
Practice Address - Phone:918-949-4086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-15
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health