Avanelle V Jack, MD

Primary specialty

Nephrology PhysicianTaxonomy code 207RN0300X

License

78666 Issued in GA

Practice address

208 Scranton Connector Ste 117
Brunswick, GA 31525-0560

Phone

(912) 264-5961

Fax

(912) 262-9499

NPI assigned

May 6, 2006

Last updated

Oct 24, 2017By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 1

Other names 1

• Dr. Avanelle V Jack-Jackson Other name

Medicare fee-for-service enrollment

Enrolled in LA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Main Street Physician Services LLC

  • Hospitalist Physician
  • New Iberia, LA
  • NPI 1396150785
  Medicare reassignment NPD
• Louisiana State University School of Medicine in New Orleans Faculty G

  dba LSU Healthcare Network

  • Multi-Specialty Clinic/Center
  • New Orleans, LA
  • NPI 1477582526
  Medicare reassignment
• Brunswick Urgent Care, LLC

  • Family Nurse Practitioner
  • Brunswick, GA
  • NPI 1023571411
  NPD
• Louisiana State University School of Medicine in New Orleans Faculty G

  dba LSU Healthcare Network Lab - Perdido

  • Clinical Medical Laboratory
  • New Orleans, LA
  • NPI 1508066283
  NPD
• Osh-in Physicians Group, PC

  • Primary Care Clinic/Center
  • Indianapolis, IN
  • NPI 1073995338
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1146873600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1508803200000",
    "number": "1316996671",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "208 SCRANTON CONNECTOR",
            "address_2": "SUITE 117",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "31525",
            "telephone_number": "912-264-5961",
            "fax_number": "912-262-9499"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "208 SCRANTON CONNECTOR STE 117",
            "city": "BRUNSWICK",
            "state": "GA",
            "postal_code": "315250560",
            "telephone_number": "912-264-5961",
            "fax_number": "912-262-9499"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "JACK",
        "first_name": "AVANELLE",
        "middle_name": "V",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2006-05-06",
        "last_updated": "2017-10-24",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207RN0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Nephrology",
            "state": "LA",
            "license": "MD.022645",
            "primary": false
        },
        {
            "code": "207RN0300X",
            "taxonomy_group": "",
            "desc": "Internal Medicine, Nephrology",
            "state": "GA",
            "license": "78666",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1491501",
            "state": "LA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "AVANELLE",
            "last_name": "JACK-JACKSON",
            "middle_name": "V",
            "prefix": "DR.",
            "credential": "MD",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

• J Melvin Deese Jr, MD PC (Summit Ambulatory Surgery Center)
• J.H. Harvey Co., LLC (Harveys Supermarket Pharmacy #2312)
• J.H. Harvey Co., LLC (Harveys Supermarket Pharmacy #2397)
• Seema Banu Jabbar
• Pauline Laggui Jacinto, M.D.
• Demetria Jackson, CCC-SLP
• Ebony Jackson
• Jenna L. Jackson
• Jennifer Jackson, RN
• Kierra Jackson

• Nephrology Physician in Brunswick, GA
• Providers in Brunswick, GA by specialty
• Nephrology Physician in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 24, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.