Healthcare Provider Details

I. General information

NPI: 1003344995
Provider Name (Legal Business Name): JAAZAR SHALABI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E TRAVIS BLVD
FAIRFIELD CA
94533-3958
US

IV. Provider business mailing address

3636 4TH AVE STE 304
SAN DIEGO CA
92103-4294
US

V. Phone/Fax

Practice location:
  • Phone: 510-424-6391
  • Fax:
Mailing address:
  • Phone: 626-660-6916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number122270
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number108481
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number108481
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number108481
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: