Provider Demographics
NPI:1457542870
Name:SHAW, JEREMIAH LAWRENCE
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:LAWRENCE
Last Name:SHAW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2155 FELSPAR ST
Mailing Address - Street 2:APT 1
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-3624
Mailing Address - Country:US
Mailing Address - Phone:646-251-2486
Mailing Address - Fax:
Practice Address - Street 1:2155 FELSPAR ST
Practice Address - Street 2:APT 1
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-3624
Practice Address - Country:US
Practice Address - Phone:646-251-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2007-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health