Provider Demographics
NPI:1780106278
Name:SHAW, JENESIS WYNETTE (LPC)
Entity type:Individual
Prefix:
First Name:JENESIS
Middle Name:WYNETTE
Last Name:SHAW
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 ENNIS JOSLIN RD APT 115
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78412-4339
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1546 S BROWNLEE BLVD
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78404-3142
Practice Address - Country:US
Practice Address - Phone:361-886-6963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2017-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX65438101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional