Healthcare Provider Details

I. General information

NPI: 1912870528
Provider Name (Legal Business Name): JACOB SAMPLES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 HAMPSHIRE RD STE R
THOUSAND OAKS CA
91361-6006
US

IV. Provider business mailing address

27182 PUMPKIN ST
MURRIETA CA
92562-4583
US

V. Phone/Fax

Practice location:
  • Phone: 805-405-3049
  • Fax:
Mailing address:
  • Phone: 805-405-3049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: