Provider Demographics
NPI:1871188789
Name:SHAW, JILL SUZANNE (MED, RD, LDN)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:SUZANNE
Last Name:SHAW
Suffix:
Gender:F
Credentials:MED, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8109 MOORES MILL CT
Mailing Address - Street 2:
Mailing Address - City:STOKESDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27357-9484
Mailing Address - Country:US
Mailing Address - Phone:336-613-1347
Mailing Address - Fax:
Practice Address - Street 1:912 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1513
Practice Address - Country:US
Practice Address - Phone:336-455-2358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
916193133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered