NPIMap

Organization Active NPI

Fairfax Mental Health & Wellness

  • Clinical Psychologist
  • Fairfax, VA
National Provider Identifier
1699201749
Registry record updated Feb 19, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical PsychologistTaxonomy code 103TC0700X
Legal business name
FAIRFAX MENTAL HEALTH & WELLNESS
Practice address
3554 Chain Bridge Rd Ste 200
Fairfax, VA 22030-2709
Phone
(703) 896-7628
NPI assigned
May 11, 2017
Last updated
Feb 19, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 19, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Jon Shore
Title
Ceo
Phone
(732) 996-6164

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Professional Counselor 101YP2500X
Clinical Psychologist 103TC0700X Primary
Clinical Social Worker 1041C0700X
Psychiatry Physician 2084P0800X

Addresses

Primary practice location

3554 Chain Bridge Rd Ste 200
Fairfax, VA 22030-2709

Mailing address

3554 Chain Bridge Rd Ste 200
Fairfax, VA 22030-2709
Phone (703) 896-7628

National Provider Directory

National Provider Directory

Locations

3554 Chain Bridge Rd
Ste 103
Fairfax, VA 22030
Phone (703) 873-7672

3554 Chain Bridge Rd
Ste 200
Fairfax, VA 22030
Phone (703) 896-7628

Practitioners & affiliated clinicians

Practitioners 33

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 33

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1494460800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1739923200000",
    "number": "1699201749",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3554 CHAIN BRIDGE RD STE 200",
            "city": "FAIRFAX",
            "state": "VA",
            "postal_code": "220302709",
            "telephone_number": "703-896-7628",
            "fax_number": "703-890-2359"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3554 CHAIN BRIDGE RD STE 200",
            "city": "FAIRFAX",
            "state": "VA",
            "postal_code": "220302709",
            "telephone_number": "703-896-7628"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAIRFAX MENTAL HEALTH & WELLNESS",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-05-11",
        "last_updated": "2025-02-19",
        "certification_date": "2025-02-19",
        "status": "A",
        "authorized_official_last_name": "SHORE",
        "authorized_official_first_name": "JON",
        "authorized_official_title_or_position": "CEO",
        "authorized_official_telephone_number": "732-996-6164",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "101YP2500X",
            "taxonomy_group": "",
            "desc": "Counselor, Professional",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "2084P0800X",
            "taxonomy_group": "",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fairfax, VA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 19, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.