Jack William Shaw, ED.D., LMHC

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

MH21197 Issued in FL

Practice address

1735 Dr MLK Jr Street South
St Petersburg, FL 33705-2547

Phone

(727) 502-0188

NPI assigned

Dec 3, 2020

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in FL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Mental Health Counselor

Education

Other, 2018

Medicare assignment

May accept Medicare assignment

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Suncoast Center, Inc.

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • St Petersburg, FL
  • NPI 1659371763
  Medicare reassignment
• Westcare Gulfcoast Florida Inc

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • St Petersburg, FL
  • NPI 1699372490
  NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1606953600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1667347200000",
    "number": "1124623319",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "7780 49TH ST N # 254",
            "city": "PINELLAS PARK",
            "state": "FL",
            "postal_code": "337813440"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1735 DR MLK JR STREET SOUTH",
            "city": "ST PETERSBURG",
            "state": "FL",
            "postal_code": "337052547",
            "telephone_number": "727-502-0188"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SHAW",
        "first_name": "JACK",
        "middle_name": "WILLIAM",
        "name_prefix": "Dr.",
        "credential": "ED.D., LMHC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2020-12-03",
        "last_updated": "2022-11-02",
        "certification_date": "2022-10-31",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "FL",
            "license": "MCAP100243",
            "primary": false
        },
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "FL",
            "license": "MH21197",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "jack.shaw@westcare.com",
            "affiliation": "Y",
            "endpointDescription": "business email",
            "affiliationName": "WestCare GulfCoast Florida, Inc",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "email",
            "address_1": "1801 5th Ave N",
            "city": "St Petersburg",
            "state": "FL",
            "country_code": "US",
            "postal_code": "337137109",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Merrily Shary, M.S
• Lisa Mae Shaub, FNP-C
• Tracy Darlene Shaver Schlabach
• Ashleigh Elizabeth Shaver, FNP-C
• Aiyana Marie Shaw
• Kevin Shaw, OT
• Kyra Nicole Shaw, MS, RD, LD
• Kay Marie Shawchuck, M.D.
• Amanda Shay
• James Shea

• Mental Health Counselor in St Petersburg, FL
• Providers in St Petersburg, FL by specialty
• Mental Health Counselor in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 2, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.