Provider Demographics
NPI:1669207676
Name:JACOBS, AVERY
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:JACOBS
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 1:1980 7TH ST W APT 101
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55116-3202
Mailing Address - Country:US
Mailing Address - Phone:651-353-8559
Mailing Address - Fax:
Practice Address - Street 1:731 BIELENBERG DR STE 102-104
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1700
Practice Address - Country:US
Practice Address - Phone:612-439-4653
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician