Healthcare Provider Details

I. General information

NPI: 1073472445
Provider Name (Legal Business Name): JESUS DOMINGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2026
Last Update Date: 01/20/2026
Certification Date: 01/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9208 BLOOMFIELD AVE APT 91
CYPRESS CA
90630-2451
US

IV. Provider business mailing address

9208 BLOOMFIELD AVE APT 91
CYPRESS CA
90630-2451
US

V. Phone/Fax

Practice location:
  • Phone: 714-494-5171
  • Fax:
Mailing address:
  • Phone: 714-494-5171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: