Provider Demographics
NPI:1114587755
Name:TRIMBLE, JALISSA LAFAYE
Entity Type:Individual
Prefix:
First Name:JALISSA
Middle Name:LAFAYE
Last Name:TRIMBLE
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 1:2921 PARKER AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-3319
Mailing Address - Country:US
Mailing Address - Phone:229-589-0562
Mailing Address - Fax:
Practice Address - Street 1:101 H ST STE L
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-5100
Practice Address - Country:US
Practice Address - Phone:866-206-2008
Practice Address - Fax:866-317-1665
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician