Basic Information
Provider Information
NPI: 1003003427
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MCEWAN
FirstName: JENNIFER
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: PH.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1707 BELLE VIEW BLVD
Address2: C-1
City: ALEXANDRIA
State: VA
PostalCode: 223076727
CountryCode: US
TelephoneNumber: 7037651400
FaxNumber:  
Practice Location
Address1: 1707 BELLE VIEW BLVD
Address2: C-1
City: ALEXANDRIA
State: VA
PostalCode: 223076727
CountryCode: US
TelephoneNumber: 7037651400
FaxNumber:  
Other Information
ProviderEnumerationDate: 09/30/2007
LastUpdateDate: 09/30/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
103TC0700X0810003739VAY Behavioral Health & Social Service ProvidersPsychologistClinical

No ID Information.


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