Provider Demographics
NPI:1306063334
Name:JESTER, RANDY L (HIS)
Entity type:Individual
Prefix:
First Name:RANDY
Middle Name:L
Last Name:JESTER
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 1:29800 BRADLEY ROAD
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586
Mailing Address - Country:US
Mailing Address - Phone:951-246-8229
Mailing Address - Fax:
Practice Address - Street 1:29800 BRADLEY RD
Practice Address - Street 2:SUITE 114
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-6520
Practice Address - Country:US
Practice Address - Phone:951-246-8229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2009-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA1572237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ80008ZOtherCA STATE ID NUMBER
CA611671400OtherDOL FECA PROVIDER NUMBER
CAZZZ80008ZOtherCA STATE ID NUMBER