Provider Demographics
NPI:1346444015
Name:SHAW, JENNIFER GALE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:GALE
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:GALE
Other - Last Name:HALEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6678 W THUNDERBIRD RD
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85306-3721
Mailing Address - Country:US
Mailing Address - Phone:602-978-1500
Mailing Address - Fax:602-978-0409
Practice Address - Street 1:6678 W THUNDERBIRD RD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85306-3721
Practice Address - Country:US
Practice Address - Phone:602-978-1500
Practice Address - Fax:602-978-0409
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA88810207V00000X
AZ61224207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ61224OtherMEDICAL LICENSE
CAA88810OtherLICENSE