1023212891 NPI number — MRS. JACKIE L. SHAW M.ED,, LPC, LMFT

Table of content: MRS. JACKIE L. SHAW M.ED,, LPC, LMFT (NPI 1023212891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023212891 NPI number — MRS. JACKIE L. SHAW M.ED,, LPC, LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
JACKIE
Provider Middle Name:
L.
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.ED,, LPC, LMFT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WHITE
Provider Other First Name:
JACKIE
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1023212891
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 755
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CRESCENT
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73028-0755
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-550-1038
Provider Business Mailing Address Fax Number:
405-285-4767

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 E DANFORTH RD
Provider Second Line Business Practice Location Address:
SUITE 118
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73034-4483
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-285-4700
Provider Business Practice Location Address Fax Number:
405-285-4767
Provider Enumeration Date:
06/13/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  LPC #1123, LMFT#655 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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