Provider Demographics
NPI:1669225769
Name:JACOME, SAMANTHA MERCEDES
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:MERCEDES
Last Name:JACOME
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 1:5956 SYCAMORE CANYON BLVD APT 2040
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-0799
Mailing Address - Country:US
Mailing Address - Phone:909-641-1654
Mailing Address - Fax:
Practice Address - Street 1:5956 SYCAMORE CANYON BLVD APT 2040
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0799
Practice Address - Country:US
Practice Address - Phone:909-641-1654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician