MEDICARE: CAROL JABASA RDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian		CA

General Provider Information

NPI Number	:	1629596366
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROL JABASA RDN

Provider Business Mailing Address
First Line	:	4030 PORTE LA PAZ UNIT 85
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92122-1984
Country	:	US
Telephone Number	:	858-453-2364
Fax Number	:

Provider Business Practice Location Address
First Line	:	4030 PORTE LA PAZ UNIT 85
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92122-1984
Country	:	US
Telephone Number	:	858-453-2364
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2017
Last Update Date	:	07/21/2022

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