Healthcare Provider Details

I. General information

NPI: 1174805147
Provider Name (Legal Business Name): JESSICA RAE SHAW MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2011
Last Update Date: 04/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N LINCOLN AVE SUTIE 2900
OKLAHOMA CITY OK
73104
US

IV. Provider business mailing address

5701 N PORTLAND AVE STE 125
OKLAHOMA CITY OK
73112-1670
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-3652
  • Fax: 405-271-7522
Mailing address:
  • Phone: 405-604-4498
  • Fax: 405-604-4195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number1644
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: