Provider Demographics
NPI:1730577073
Name:SHAW, JEFFREY (CRC, LCASA)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:
Last Name:SHAW
Suffix:
Gender:M
Credentials:CRC, LCASA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3098 GLEN LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-4454
Mailing Address - Country:US
Mailing Address - Phone:336-287-5063
Mailing Address - Fax:
Practice Address - Street 1:3098 GLEN LAUREL LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-4454
Practice Address - Country:US
Practice Address - Phone:336-287-5063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2015-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20257101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)