Provider Demographics
NPI:1639805708
Name:MOURAS, JACLYN (PSYD)
Entity type:Individual
Prefix:
First Name:JACLYN
Middle Name:
Last Name:MOURAS
Suffix:
Gender:
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 IVY RIDGE LN STE A14
Mailing Address - Street 2:
Mailing Address - City:FISHERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22939-2354
Mailing Address - Country:US
Mailing Address - Phone:540-221-1846
Mailing Address - Fax:
Practice Address - Street 1:16 IVY RIDGE LN STE A14
Practice Address - Street 2:
Practice Address - City:FISHERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22939-2354
Practice Address - Country:US
Practice Address - Phone:540-221-1846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007904103TC0700X, 103G00000X
171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No171400000XOther Service ProvidersHealth & Wellness Coach