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NPI Code Detail

MEDICARE: MRS. JESSICA LORI SHAW PT

MEDICARE: MRS. JESSICA LORI SHAW PT
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1225100000XPhysical TherapistPT007002GA
2225100000XPhysical Therapist6258TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
14021800OTHERTNBCBS
2TN0100OTHERTNJOHN DEERE

General Provider Information

NPI Number : 1689670895
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. JESSICA LORI SHAW PT
Provider Business Mailing Address
First Line : 2415 MCCALLIE AVE
Second Line :
City : CHATTANOOGA
State : TN
Zip : 37404-3322
Country : US
Telephone Number : 423-622-6200
Fax Number : 423-697-2025
Provider Business Practice Location Address
First Line : 2415 MCCALLIE AVE
Second Line :
City : CHATTANOOGA
State : TN
Zip : 37404-3322
Country : US
Telephone Number : 423-622-6200
Fax Number : 423-697-2025
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/22/2005
Last Update Date : 10/30/2007

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