Provider Demographics
NPI:1982118220
Name:SHAW, JILLIAN DENISE (NP-C)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:DENISE
Last Name:SHAW
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7450 SILVER LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45068-8230
Mailing Address - Country:US
Mailing Address - Phone:937-903-4442
Mailing Address - Fax:
Practice Address - Street 1:400 E BUSINESS WAY
Practice Address - Street 2:
Practice Address - City:SHARONVILLE
Practice Address - State:OH
Practice Address - Zip Code:45241-3089
Practice Address - Country:US
Practice Address - Phone:952-687-4088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-22
Last Update Date:2020-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022082363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0306558Medicaid