Provider Demographics
NPI:1770466757
Name:MERCASDO SAMANO, JAIRO R
Entity type:Individual
Prefix:
First Name:JAIRO
Middle Name:R
Last Name:MERCASDO SAMANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 BLUE RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-9234
Mailing Address - Country:US
Mailing Address - Phone:909-534-7349
Mailing Address - Fax:909-534-7349
Practice Address - Street 1:1120 BLUE RIDGE LN
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4702
Practice Address - Country:US
Practice Address - Phone:909-534-7349
Practice Address - Fax:909-534-7349
Is Sole Proprietor?:No
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician