Healthcare Provider Details

I. General information

NPI: 1972419521
Provider Name (Legal Business Name): JORDAN SIBLEY RN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

537 RENAISSANCE WAY UNIT 105
SANTA ROSA CA
95403-0050
US

IV. Provider business mailing address

537 RENAISSANCE WAY UNIT 105
SANTA ROSA CA
95403-0050
US

V. Phone/Fax

Practice location:
  • Phone: 317-910-8301
  • Fax:
Mailing address:
  • Phone: 317-910-8301
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberL-312487
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: