Provider Demographics
NPI:1912605635
Name:SHAW, JILLIEN AMENSIE
Entity type:Individual
Prefix:MRS
First Name:JILLIEN
Middle Name:AMENSIE
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 1:20 CHADSFORD LN
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-8727
Mailing Address - Country:US
Mailing Address - Phone:845-857-4945
Mailing Address - Fax:
Practice Address - Street 1:92 YONKERS AVE
Practice Address - Street 2:
Practice Address - City:TUCKAHOE
Practice Address - State:NY
Practice Address - Zip Code:10707-3911
Practice Address - Country:US
Practice Address - Phone:914-337-6033
Practice Address - Fax:914-337-7218
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP119122101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY153143259OtherDRIVERS LICENSE