Basic Information
| Provider Information | |||||||||
| NPI: | 1346444015 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHAW | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | GALE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HALEM | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | GALE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6678 W THUNDERBIRD RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853063721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029781500 | ||||||||
| FaxNumber: | 6029780409 | ||||||||
| Practice Location | |||||||||
| Address1: | 6678 W THUNDERBIRD RD | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853063721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029781500 | ||||||||
| FaxNumber: | 6029780409 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2007 | ||||||||
| LastUpdateDate: | 03/12/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | A88810 | CA | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 61224 | AZ | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 61224 | 01 | AZ | MEDICAL LICENSE | OTHER | A88810 | 01 | CA | LICENSE | OTHER |