Individual
JACIE SHAW
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
60 BUCA RUN, PORTLAND, ME 04103-1427
(204) 624-2464
Mailing address
60 BUCA RUN, PORTLAND, ME 04103-1427
(204) 624-2464
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
MC12587
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
435945899
PROVIDER ENROLLMENT
ME
Enumeration date
08/25/2010
Last updated
08/25/2010
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