Provider Demographics
NPI:1073933974
Name:SHAW, JASON (BCBA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 W ETHEL AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-4402
Mailing Address - Country:US
Mailing Address - Phone:765-282-8222
Mailing Address - Fax:765-282-8222
Practice Address - Street 1:2810 W ETHEL AVE STE 1
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-4402
Practice Address - Country:US
Practice Address - Phone:765-282-8222
Practice Address - Fax:765-282-8222
Is Sole Proprietor?:No
Enumeration Date:2014-04-18
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1-13-14641103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst