Provider Demographics
NPI:1417162389
Name:SHAW, JESSIE (MS, LAC, OM)
Entity Type:Individual
Prefix:MS
First Name:JESSIE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:MS, LAC, OM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 BEDFORD ST APT 4A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-5361
Mailing Address - Country:US
Mailing Address - Phone:917-864-3026
Mailing Address - Fax:
Practice Address - Street 1:242 E 5TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-8501
Practice Address - Country:US
Practice Address - Phone:917-864-3026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002135171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist