Provider Demographics
NPI:1922763648
Name:SHAW, JERRY
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
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 1:1208 HALL STREET
Mailing Address - Street 2:
Mailing Address - City:HYDE
Mailing Address - State:PA
Mailing Address - Zip Code:16830
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1208 HALL STREET
Practice Address - Street 2:
Practice Address - City:HYDE
Practice Address - State:PA
Practice Address - Zip Code:16830
Practice Address - Country:US
Practice Address - Phone:814-553-5312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator