Healthcare Provider Details

I. General information

NPI: 1972931335
Provider Name (Legal Business Name): JENNIFER DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2013
Last Update Date: 09/07/2022
Certification Date: 09/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PRISON RD
REPRESA CA
95671-0066
US

IV. Provider business mailing address

PO BOX 290066
REPRESA CA
95671-0066
US

V. Phone/Fax

Practice location:
  • Phone: 916-985-8610
  • Fax: 916-294-3121
Mailing address:
  • Phone: 916-985-8610
  • Fax: 916-294-3121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21676
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: