Provider Demographics
NPI:1548414378
Name:BEAMESDERFER, JACOB SAMUEL (HIS)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:SAMUEL
Last Name:BEAMESDERFER
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3980 W FLORIDA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-5258
Mailing Address - Country:US
Mailing Address - Phone:951-925-9948
Mailing Address - Fax:951-925-8333
Practice Address - Street 1:3980 W FLORIDA AVE STE 102
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-5258
Practice Address - Country:US
Practice Address - Phone:951-925-9948
Practice Address - Fax:951-925-8333
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA7424237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27-3716562Medicaid