Healthcare Provider Details

I. General information

NPI: 1851256499
Provider Name (Legal Business Name): JENNIFER DORMAN LAC-T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3800 N CENTRAL AVE STE 1010
PHOENIX AZ
85012-1918
US

IV. Provider business mailing address

19401 N 7TH ST LOT 201
PHOENIX AZ
85024-1653
US

V. Phone/Fax

Practice location:
  • Phone: 602-669-3948
  • Fax:
Mailing address:
  • Phone: 602-669-3948
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberLAC-08374T
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: