Provider Demographics
NPI:1700969383
Name:MALLERY, JACK EUGENE (LPC)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:EUGENE
Last Name:MALLERY
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2114 BAYBERRY ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1402
Mailing Address - Country:US
Mailing Address - Phone:757-481-2485
Mailing Address - Fax:
Practice Address - Street 1:7305 HAMPTON BLVD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23505-2908
Practice Address - Country:US
Practice Address - Phone:757-623-2700
Practice Address - Fax:757-640-1058
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0718000021101YA0400X
VA0701002423101YM0800X
175T00000X
VA0717000586106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004945395OtherPROVIDER NUMBER
VA175080OtherPROVIDER NUMBER
VA004945395Medicaid
VA083239MOtherPROVIDER NUMBER