Provider Demographics
NPI:1417969429
Name:SHAW, JESSICA R (AGACNP-BC)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:R
Last Name:SHAW
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-3004
Mailing Address - Country:US
Mailing Address - Phone:817-229-3665
Mailing Address - Fax:
Practice Address - Street 1:800 W MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4611
Practice Address - Country:US
Practice Address - Phone:817-759-7000
Practice Address - Fax:817-759-7027
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX637618163WN0800X
TXAP132391363LA2100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care