Provider Demographics
NPI:1235428459
Name:SHAW, JESSICA ANNA (MED, LMFT)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ANNA
Last Name:SHAW
Suffix:
Gender:F
Credentials:MED, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 E BROADWAY BLVD STE B200
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710-3514
Mailing Address - Country:US
Mailing Address - Phone:520-822-6472
Mailing Address - Fax:520-795-4981
Practice Address - Street 1:6420 E BROADWAY BLVD STE B200
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710-3514
Practice Address - Country:US
Practice Address - Phone:520-822-6472
Practice Address - Fax:520-795-4981
Is Sole Proprietor?:No
Enumeration Date:2011-03-29
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT-10433106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist