Active NPI
Jacob R Shaw
- Peer Specialist
- Basin, WY
National Provider Identifier
1396513719
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Peer Specialist
- License
- 143
- Practice address
- 116 South 3Rd Street
Basin, WY 82410 - Phone
- (307) 568-2020
- NPI assigned
- Dec 14, 2023
- Last updated
- Dec 14, 2023
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Peer Specialist | 175T00000X | 143 | WY | Primary |
Addresses
Primary practice location
116 South 3Rd Street
Basin, WY 82410
Mailing address
1114 Lane 12
Lovell, WY 82431-9555
Phone (307) 548-6543
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 143 | WY | MD | Registered Dietitian |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1702512000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1702512000000",
"number": "1396513719",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1114 LANE 12",
"city": "LOVELL",
"state": "WY",
"postal_code": "824319555",
"telephone_number": "307-548-6543"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "116 SOUTH 3RD STREET",
"city": "BASIN",
"state": "WY",
"postal_code": "82410",
"telephone_number": "307-568-2020"
}
],
"practiceLocations": [],
"basic": {
"last_name": "SHAW",
"first_name": "JACOB",
"middle_name": "R",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2023-12-14",
"last_updated": "2023-12-14",
"certification_date": "2023-12-13",
"status": "A"
},
"taxonomies": [
{
"code": "175T00000X",
"taxonomy_group": "",
"desc": "Peer Specialist",
"state": "WY",
"license": "143",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Basin, WY
- David Sherwin Peterson, DDS
- Enrika Rain Joy Potter, FNP
- Emily Pustelnik, DPT
- Andrew L Roberts, D.O.
- Carissa Rohrbach, DPT
- Jesi Skretteberg, RN
- Christine Mae Smith, R.N.
- South Big Horn County Hospital District (South Big Horn County Critical Access Hospital)
- South Big Horn County Hospital District (Bonnie BlueJacket Memorial Nursing Home)
- South Big Horn County Hospital District
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 14, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.