=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043721376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON S SHAW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2017
-----------------------------------------------------
Last Update Date | 07/10/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 147 SAYLES BLVD
-----------------------------------------------------
City | ABILENE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79605-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-437-1852
-----------------------------------------------------
Fax | 325-437-4082
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 294 MEDICAL DR
-----------------------------------------------------
City | ABILENE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79601-4554
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-437-6859
-----------------------------------------------------
Fax | 325-437-4082
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 74762
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 74762
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------