Provider Demographics
NPI:1457704793
Name:SHAW, JARON LAVELL
Entity Type:Individual
Prefix:
First Name:JARON
Middle Name:LAVELL
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 1:1818 N MIDLAND AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74106-5620
Mailing Address - Country:US
Mailing Address - Phone:760-277-7381
Mailing Address - Fax:
Practice Address - Street 1:1860 E 15TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4611
Practice Address - Country:US
Practice Address - Phone:918-949-4430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255R0406X
OK101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No2255R0406XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistRehabilitation, Blind