Provider Demographics
NPI:1932924230
Name:WASONGA-AGAK, JACOBETT NAOMIE O (DNP, CNS, RN)
Entity type:Individual
Prefix:
First Name:JACOBETT
Middle Name:NAOMIE O
Last Name:WASONGA-AGAK
Suffix:
Gender:U
Credentials:DNP, CNS, RN
Other - Prefix:
Other - First Name:JACOBETT
Other - Middle Name:
Other - Last Name:AMBOKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3365 WACO AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-1225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15107 VANOWEN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4597
Practice Address - Country:US
Practice Address - Phone:818-205-7137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-21
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95157691163W00000X
CA4920364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163W00000XNursing Service ProvidersRegistered Nurse