Provider Demographics
NPI:1841530128
Name:SHAW, JESSICA LYNN (LPC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:SHAW
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:S73W16485 JANESVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MUSKEGO
Mailing Address - State:WI
Mailing Address - Zip Code:53150-8960
Mailing Address - Country:US
Mailing Address - Phone:262-221-0369
Mailing Address - Fax:
Practice Address - Street 1:S73W16485 JANESVILLE RD STE 202
Practice Address - Street 2:
Practice Address - City:MUSKEGO
Practice Address - State:WI
Practice Address - Zip Code:53150-8960
Practice Address - Country:US
Practice Address - Phone:262-221-0369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-22
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6502-125101YP2500X, 101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100092725Medicaid