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General NPI Number Information
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NPI Number | 1790371227
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Entity Type | Individual
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Provider Name | JASON SHAW JR. MA, LPC
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Gender | Male
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Dates
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Enumeration Date | 12/18/2020
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Last Update Date | 12/18/2020
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Provider Practice Location Address
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Address Line | 2000 N RACINE AVE STE 3300
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City | CHICAGO
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State | IL
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Zip | 60614-4045
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Country | US
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Telephone | 312-718-9464
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Fax |
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Provider Business Mailing Address
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Address Line | 3133 N HARDING AVE
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City | CHICAGO
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State | IL
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Zip | 60618-6510
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 178.016637
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License Number State | IL
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