Provider Demographics
NPI:1083505481
Name:SHAW, JACOB AUSTIN (PARAMEDIC)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:AUSTIN
Last Name:SHAW
Suffix:
Gender:M
Credentials:PARAMEDIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6704 SMITHFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9106
Mailing Address - Country:US
Mailing Address - Phone:317-619-6884
Mailing Address - Fax:317-619-6884
Practice Address - Street 1:6704 SMITHFIELD BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9106
Practice Address - Country:US
Practice Address - Phone:317-619-6884
Practice Address - Fax:317-619-6884
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-14
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INM5148988171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider