Provider Demographics
NPI:1083006365
Name:JACK A MERENDA, PSY.D., INC.
Entity Type:Organization
Organization Name:JACK A MERENDA, PSY.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:MERENDA
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:703-474-8905
Mailing Address - Street 1:9306 OLD KEENE MILL RD
Mailing Address - Street 2:B
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-4280
Mailing Address - Country:US
Mailing Address - Phone:703-474-8905
Mailing Address - Fax:
Practice Address - Street 1:9306 OLD KEENE MILL RD
Practice Address - Street 2:B
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-4280
Practice Address - Country:US
Practice Address - Phone:703-474-8905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810005120101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty