Provider Demographics
NPI:1578133062
Name:SHAW, JILL RODRIGUEZ
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:RODRIGUEZ
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 W COLORADO BLVD STE 525
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75208-2312
Mailing Address - Country:US
Mailing Address - Phone:214-960-5681
Mailing Address - Fax:
Practice Address - Street 1:221 W COLORADO BLVD STE 525
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75208-2312
Practice Address - Country:US
Practice Address - Phone:214-960-5681
Practice Address - Fax:214-960-5681
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1012936363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner