Provider Demographics
NPI:1770247090
Name:SHAW, JESSICA LOUISE (BHA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LOUISE
Last Name:SHAW
Suffix:
Gender:F
Credentials:BHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 1ST AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4899
Mailing Address - Country:US
Mailing Address - Phone:907-452-8251
Mailing Address - Fax:
Practice Address - Street 1:806 G STREET
Practice Address - Street 2:
Practice Address - City:NENANA
Practice Address - State:AK
Practice Address - Zip Code:99760
Practice Address - Country:US
Practice Address - Phone:907-452-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-22
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)