Provider Demographics
NPI:1619435815
Name:ALICBUSAN, JENNIFER CRUZ (FNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:CRUZ
Last Name:ALICBUSAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 CINNABAR WAY
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-1717
Mailing Address - Country:US
Mailing Address - Phone:510-734-6121
Mailing Address - Fax:
Practice Address - Street 1:1100 TRANCAS ST STE 205
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-2904
Practice Address - Country:US
Practice Address - Phone:707-251-3604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011187363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner