Provider Demographics
NPI:1811100241
Name:SHAW, JESSAMYN (PTA,)
Entity type:Individual
Prefix:
First Name:JESSAMYN
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:PTA,
Other - Prefix:
Other - First Name:JESS
Other - Middle Name:
Other - Last Name:BELCHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6717 CHAMBERS LAKE CT
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-2384
Mailing Address - Country:US
Mailing Address - Phone:760-409-9684
Mailing Address - Fax:
Practice Address - Street 1:2250 E FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-5170
Practice Address - Country:US
Practice Address - Phone:702-784-4303
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2015-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 8021225200000X
NVA-0669225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant