Provider Demographics
NPI:1316099435
Name:SHAW, JEFFREY ALLEN (PSY D)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:ALLEN
Last Name:SHAW
Suffix:
Gender:M
Credentials:PSY D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34036
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1036
Mailing Address - Country:US
Mailing Address - Phone:425-899-3292
Mailing Address - Fax:
Practice Address - Street 1:12303 NE 130TH LN
Practice Address - Street 2:SUTIE 325
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-3099
Practice Address - Country:US
Practice Address - Phone:425-899-3140
Practice Address - Fax:425-899-3131
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY00002441103TC0700X, 103TB0200X, 103TA0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8372013Medicaid
WAG8877178Medicare PIN
WAS94676Medicare UPIN