=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164753752
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNY GRACE SHAW LMHC, CPT, CWS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/20/2010
-----------------------------------------------------
Last Update Date | 12/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1450 S KIHEI RD B201
-----------------------------------------------------
City | KIHEI
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96753-8154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-344-5404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1450 S KIHEI RD B201
-----------------------------------------------------
City | KIHEI
-----------------------------------------------------
State | HI
-----------------------------------------------------
Zip | 96753-8154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 808-344-5404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 256964
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | MHC 207
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LH60703859
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------