=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164100251
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEJANDRA JUAREZ SHUTTLEWORTH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2023
-----------------------------------------------------
Last Update Date | 08/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3450 3RD ST STE 1C
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94124-1444
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-437-3990
-----------------------------------------------------
Fax | 415-437-3994
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 SOLANO SQ # 208
-----------------------------------------------------
City | BENICIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94510-2712
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-410-1005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | AMFT148834
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------