Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101Y00000X | Counselor | ||
Y | 103TC1900X | Counseling Psychologist | 6362009479 | MI |
NPI | 1053065797 |
---|---|
Provider Name | Mr. Jason Thomas Shaw |
First Address | Lambertville, MI 48144-9456 |
Second Address | Tecumseh, MI 49286-1611 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/02/2022 |
Last Update Date | 14/02/2022 |