Provider Demographics
NPI:1417324609
Name:SHAW, JENNIFER A (MA PSYSP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:A
Last Name:SHAW
Suffix:
Gender:F
Credentials:MA PSYSP
Other - Prefix:MRS
Other - First Name:JENNIFER
Other - Middle Name:A
Other - Last Name:SHAW
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA PSYSP
Mailing Address - Street 1:1542 APGAR RD
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:OH
Mailing Address - Zip Code:45150-9714
Mailing Address - Country:US
Mailing Address - Phone:248-895-7976
Mailing Address - Fax:
Practice Address - Street 1:9231 HAMER ROAD
Practice Address - Street 2:BROWN COUNTY EDUCATIONAL SERVICE CENTER
Practice Address - City:GEORGETOWN
Practice Address - State:OH
Practice Address - Zip Code:45121
Practice Address - Country:US
Practice Address - Phone:937-378-6118
Practice Address - Fax:937-378-4826
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool