Provider Demographics
NPI:1073709143
Name:SHAW, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:
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 242278
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36124-2278
Mailing Address - Country:US
Mailing Address - Phone:334-396-2110
Mailing Address - Fax:334-396-4905
Practice Address - Street 1:3950 COBB PKWY NW
Practice Address - Street 2:SUITE 703
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-9532
Practice Address - Country:US
Practice Address - Phone:770-917-0924
Practice Address - Fax:770-917-0926
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTH009094225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511I650125Medicare PIN