Provider Demographics
NPI:1689670895
Name:SHAW, JESSICA LORI (PT)
Entity Type:Individual
Prefix:MRS
First Name:JESSICA
Middle Name:LORI
Last Name:SHAW
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 MCCALLIE AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-3322
Mailing Address - Country:US
Mailing Address - Phone:423-622-6200
Mailing Address - Fax:423-697-2025
Practice Address - Street 1:2415 MCCALLIE AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-3322
Practice Address - Country:US
Practice Address - Phone:423-622-6200
Practice Address - Fax:423-697-2025
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT007002225100000X
TN6258225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4021800OtherBCBS
TNTN0100OtherJOHN DEERE
TNTN0100OtherJOHN DEERE