Healthcare Provider Details

I. General information

NPI: 1992692115
Provider Name (Legal Business Name): JALICIA LYNEA NASIBEBO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2025
Last Update Date: 07/20/2025
Certification Date: 07/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 CHILDRENS CIR
SANTA ROSA CA
95409-6558
US

IV. Provider business mailing address

800 MISSION BLVD APT 2
SANTA ROSA CA
95409-5339
US

V. Phone/Fax

Practice location:
  • Phone: 707-565-6322
  • Fax:
Mailing address:
  • Phone: 707-703-9011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: