Provider Demographics
NPI:1134225063
Name:AVERY, JACKIE S (DPM)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:S
Last Name:AVERY
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:
Practice Address - Street 1:161 CAREY RD
Practice Address - Street 2:
Practice Address - City:QUEENSBURY
Practice Address - State:NY
Practice Address - Zip Code:12804-7821
Practice Address - Country:US
Practice Address - Phone:518-824-8610
Practice Address - Fax:518-824-2390
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2025-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006408213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03387088Medicaid
NYJ400054779Medicare PIN
SCU816957345Medicare ID - Type Unspecified