Provider Demographics
NPI:1518300201
Name:KITAEFF, JACK (PHD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:
Last Name:KITAEFF
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 1:9020 FORT CRAIG DR
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-2115
Mailing Address - Country:US
Mailing Address - Phone:703-501-0129
Mailing Address - Fax:
Practice Address - Street 1:10560 MAIN ST
Practice Address - Street 2:SUITE 518
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-7182
Practice Address - Country:US
Practice Address - Phone:703-349-2999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1070103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical