Provider Demographics
NPI:1770576340
Name:SHAW, JILL MARIE (DO)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:MARIE
Last Name:SHAW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6564 SE LAKE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2237
Mailing Address - Country:US
Mailing Address - Phone:503-908-5880
Mailing Address - Fax:888-475-8729
Practice Address - Street 1:6564 SE LAKE RD STE 200
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2237
Practice Address - Country:US
Practice Address - Phone:503-908-5880
Practice Address - Fax:888-475-8729
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25570207V00000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
218071OtherMEDICARE PIN
OR213528Medicaid
WA1770576340Medicaid