Provider Demographics
NPI:1598758021
Name:SHAW, JACQUELINE D (MD)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
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 1:3300 WILCOX BLVD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37411-1073
Mailing Address - Country:US
Mailing Address - Phone:423-493-2100
Mailing Address - Fax:423-493-2137
Practice Address - Street 1:3300 WILCOX BLVD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-1073
Practice Address - Country:US
Practice Address - Phone:423-493-2100
Practice Address - Fax:423-493-2137
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN19823208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3050365Medicaid
3050365Medicare ID - Type Unspecified
TN3050365Medicaid