Provider Demographics
NPI:1417225863
Name:SHORE, JENNIFER LYNN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:LYNN
Last Name:SHORE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3554 CHAIN BRIDGE RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-2709
Mailing Address - Country:US
Mailing Address - Phone:703-896-7628
Mailing Address - Fax:703-890-2359
Practice Address - Street 1:3554 CHAIN BRIDGE RD
Practice Address - Street 2:SUITE 103
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-2709
Practice Address - Country:US
Practice Address - Phone:703-896-7628
Practice Address - Fax:703-890-2359
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-13
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810004513103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical