Provider Demographics
NPI:1699201749
Name:FAIRFAX MENTAL HEALTH & WELLNESS
Entity Type:Organization
Organization Name:FAIRFAX MENTAL HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-663-4041
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA810004513103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty