Healthcare Provider Details

I. General information

NPI: 1619050473
Provider Name (Legal Business Name): JACK MELVIN MERWIN PSYCHOLOGIST
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S PONCE DE LEON BLVD STE 1
SAINT AUGUSTINE FL
32084-6013
US

IV. Provider business mailing address

1100 S PONCE DE LEON BLVD STE 1
SAINT AUGUSTINE FL
32084-6013
US

V. Phone/Fax

Practice location:
  • Phone: 904-824-7733
  • Fax: 904-829-9768
Mailing address:
  • Phone: 904-824-7733
  • Fax: 904-829-9768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberPY2444
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: