Healthcare Provider Details

I. General information

NPI: 1144938069
Provider Name (Legal Business Name): JESSE ALVIN SHAW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 05/14/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

380 ENCINAL ST STE 200
SANTA CRUZ CA
95060-2178
US

IV. Provider business mailing address

604 PEARL ST
MONTEREY CA
93940-3070
US

V. Phone/Fax

Practice location:
  • Phone: 831-469-1700
  • Fax: 831-425-1905
Mailing address:
  • Phone: 831-800-7530
  • Fax: 831-425-1905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: