Provider Demographics
NPI:1992692115
Name:NASIBEBO, JALICIA LYNEA
Entity type:Individual
Prefix:
First Name:JALICIA
Middle Name:LYNEA
Last Name:NASIBEBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MISSION BLVD APT 2
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95409-5339
Mailing Address - Country:US
Mailing Address - Phone:707-703-9011
Mailing Address - Fax:
Practice Address - Street 1:112 CHILDRENS CIR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95409-6558
Practice Address - Country:US
Practice Address - Phone:707-565-6322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-20
Last Update Date:2025-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker