=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043664329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SHARAT K. JAIN, PH.D. CLINICAL PSYCHOLOGIST
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2016
-----------------------------------------------------
Last Update Date | 04/22/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3230 PENNSYLVANIA AVE SE SUITE 213
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20020-3722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-693-5513
-----------------------------------------------------
Fax | 301-765-3366
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10705 RIVER RD
-----------------------------------------------------
City | POTOMAC
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20854-4113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-693-5513
-----------------------------------------------------
Fax | 301-765-3366
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PSYCHOLOGIST
-----------------------------------------------------
Name | SHARAT K. JAIN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 301-693-5513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY1000064
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------