Provider Demographics
NPI:1649838863
Name:AVERY, JERICHO BRENT (CSW, CSUDC)
Entity type:Individual
Prefix:
First Name:JERICHO
Middle Name:BRENT
Last Name:AVERY
Suffix:
Gender:M
Credentials:CSW, CSUDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2214 E LOCH LOMOND DR
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:UT
Mailing Address - Zip Code:84043-3911
Mailing Address - Country:US
Mailing Address - Phone:385-374-9708
Mailing Address - Fax:
Practice Address - Street 1:20 S STATE ST
Practice Address - Street 2:
Practice Address - City:LINDON
Practice Address - State:UT
Practice Address - Zip Code:84042-1939
Practice Address - Country:US
Practice Address - Phone:801-441-7144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10395960-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical