1417324609 NPI number — MRS. JENNIFER A SHAW M.A. PSYSP.

Table of content: MRS. JENNIFER A SHAW M.A. PSYSP. (NPI 1417324609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417324609 NPI number — MRS. JENNIFER A SHAW M.A. PSYSP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHAW
Provider First Name:
JENNIFER
Provider Middle Name:
A
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A. PSYSP.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHAW
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.A. PSY.SP.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417324609
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1542 APGAR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILFORD
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45150-9714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-895-7976
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9231 HAMER ROAD
Provider Second Line Business Practice Location Address:
BROWN COUNTY EDUCATIONAL SERVICE CENTER
Provider Business Practice Location Address City Name:
GEORGETOWN
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-378-6118
Provider Business Practice Location Address Fax Number:
937-378-4826
Provider Enumeration Date:
08/24/2015

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: 103TS0200X , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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