Provider Demographics
NPI:1083442156
Name:SHAW, JESSIE A
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 THE PLACE CT APT A7
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3758
Mailing Address - Country:US
Mailing Address - Phone:321-432-8940
Mailing Address - Fax:
Practice Address - Street 1:109 N OAKWOOD AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33510-4629
Practice Address - Country:US
Practice Address - Phone:813-819-8704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLISW192081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical