Provider Demographics
NPI:1023212891
Name:SHAW, JACKIE L (MED,, LPC, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:L
Last Name:SHAW
Suffix:
Gender:F
Credentials:MED,, LPC, LMFT
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:L
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 755
Mailing Address - Street 2:
Mailing Address - City:CRESCENT
Mailing Address - State:OK
Mailing Address - Zip Code:73028-0755
Mailing Address - Country:US
Mailing Address - Phone:405-550-1038
Mailing Address - Fax:405-285-4767
Practice Address - Street 1:307 E DANFORTH RD
Practice Address - Street 2:SUITE 118
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-4483
Practice Address - Country:US
Practice Address - Phone:405-285-4700
Practice Address - Fax:405-285-4767
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2016-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKLPC #1123, LMFT#655101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional