Healthcare Provider Details

I. General information

NPI: 1992399489
Provider Name (Legal Business Name): JACQUELINE DOMINGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2021
Last Update Date: 01/02/2025
Certification Date: 01/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 FARRAGUT AVE
COLORADO SPRINGS CO
80909-5626
US

IV. Provider business mailing address

111 MACKENAN DR
CARY NC
27511-7903
US

V. Phone/Fax

Practice location:
  • Phone: 719-636-2122
  • Fax:
Mailing address:
  • Phone: 919-371-2848
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: