Provider Demographics
NPI:1720187347
Name:SHAW, JACQUELYN (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELYN
Middle Name:
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 1:214 TERRACE AVENUE
Mailing Address - Street 2:
Mailing Address - City:HASBROUCK HEIGHTS
Mailing Address - State:NJ
Mailing Address - Zip Code:07604
Mailing Address - Country:US
Mailing Address - Phone:201-288-6330
Mailing Address - Fax:201-288-6331
Practice Address - Street 1:214 TERRACE AVENUE
Practice Address - Street 2:
Practice Address - City:HASBROUCK HEIGHTS
Practice Address - State:NJ
Practice Address - Zip Code:07604
Practice Address - Country:US
Practice Address - Phone:201-288-6330
Practice Address - Fax:201-288-6331
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA55112207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ74437OtherGREAT WEST
NJ2043630OtherUNITED HEALTHCARE
NJ1528267OtherCIGNA
NJ2749N1OtherWELLCHOICE
NJ5180001OtherAETNA
NJ8217906OtherGHI
NJP2884936OtherOXFORD
NJ820584930OtherHORIZON BC BS OF NJ
NJJ30559OtherHEALTHNET
NJ74437OtherGREAT WEST
NJP2884936OtherOXFORD