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General NPI Number Information
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NPI Number | 1619050473
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Entity Type | Individual
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Provider Name | JACK MELVIN MERWIN PSYCHOLOGIST
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Gender | Male
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Dates
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Enumeration Date | 10/23/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1100 S PONCE DE LEON BLVD STE 1
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32084-6013
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Country | US
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Telephone | 904-824-7733
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Fax | 904-829-9768
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Provider Business Mailing Address
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Address Line | 1100 S PONCE DE LEON BLVD STE 1
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City | SAINT AUGUSTINE
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State | FL
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Zip | 32084-6013
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Country | US
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Telephone | 904-824-7733
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Fax | 904-829-9768
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TB0200X
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Taxonomy Name | Cognitive & Behavioral Psychologist
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License Number | PY2444
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License Number State | FL
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