Provider Demographics
NPI:1437581766
Name:SHAW, JENNIFER D (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:D
Last Name:SHAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 W 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:ND
Mailing Address - Zip Code:58237-1826
Mailing Address - Country:US
Mailing Address - Phone:701-352-1620
Mailing Address - Fax:
Practice Address - Street 1:164 W 13TH ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:ND
Practice Address - Zip Code:58237
Practice Address - Country:US
Practice Address - Phone:701-352-1620
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14586207Q00000X
MO2013028806390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program