Basic Information
| Provider Information | |||||||||
| NPI: | 1841574753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1599 | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044021599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079455247 | ||||||||
| FaxNumber: | 2079470435 | ||||||||
| Practice Location | |||||||||
| Address1: | 242 BRUNSWICK ST | ||||||||
| Address2: | |||||||||
| City: | OLD TOWN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044681613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078276128 | ||||||||
| FaxNumber: | 2078275533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2011 | ||||||||
| LastUpdateDate: | 10/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LS12886 | ME | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.