Provider Demographics
NPI:1689959694
Name:SHAW, JACQUELINE (LPC)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 WEATHERVANE WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-8736
Mailing Address - Country:US
Mailing Address - Phone:252-451-0148
Mailing Address - Fax:
Practice Address - Street 1:633 WEATHERVANE WAY
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27803-8736
Practice Address - Country:US
Practice Address - Phone:252-451-0148
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-21
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8086101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional