Provider Demographics
NPI:1215231303
Name:SHAW, JENNIFER LEA (LISW)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:LEA
Last Name:SHAW
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2019 WESTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-3719
Mailing Address - Country:US
Mailing Address - Phone:319-610-1612
Mailing Address - Fax:319-235-3069
Practice Address - Street 1:215 E 4TH ST
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-4701
Practice Address - Country:US
Practice Address - Phone:319-236-7290
Practice Address - Fax:319-235-4875
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-04
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA061981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical