Healthcare Provider Details

I. General information

NPI: 1417864471
Provider Name (Legal Business Name): JADIE MARIE SHAW ALC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 E LEE ST STE C
ENTERPRISE AL
36330-2477
US

IV. Provider business mailing address

2394 COUNTY ROAD 13
HEADLAND AL
36345-8565
US

V. Phone/Fax

Practice location:
  • Phone: 334-333-4940
  • Fax:
Mailing address:
  • Phone: 334-333-4940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberALC06153
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: