Provider Demographics
NPI:1780875906
Name:PEVERILL, JACK ARTHUR (PHD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ARTHUR
Last Name:PEVERILL
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4724 ACORN CIRCLE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34233-3935
Mailing Address - Country:US
Mailing Address - Phone:941-924-6113
Mailing Address - Fax:941-924-6113
Practice Address - Street 1:2163 SOUTH TAMIAMI TRAIL
Practice Address - Street 2:
Practice Address - City:OSPREY
Practice Address - State:FL
Practice Address - Zip Code:34229-9696
Practice Address - Country:US
Practice Address - Phone:941-924-6113
Practice Address - Fax:941-924-6113
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2007-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 3601103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent