Provider Demographics
NPI:1225820269
Name:SHAW, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:SHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10658 OLALLA VALLEY RD SE
Mailing Address - Street 2:
Mailing Address - City:OLALLA
Mailing Address - State:WA
Mailing Address - Zip Code:98359-9738
Mailing Address - Country:US
Mailing Address - Phone:801-520-6010
Mailing Address - Fax:
Practice Address - Street 1:950 BROADWAY STE 301
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4454
Practice Address - Country:US
Practice Address - Phone:253-292-4354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-17
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician