Healthcare Provider Details

I. General information

NPI: 1447910864
Provider Name (Legal Business Name): CRICKET HEALTH MEDICAL PRACTICE OF NEW JERSEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2021
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 HARRISON AVE STE 39516
BOSTON MA
02111-1929
US

IV. Provider business mailing address

68 HARRISON AVE STE 605 PMB 39516
BOSTON MA
02111-2327
US

V. Phone/Fax

Practice location:
  • Phone: 888-780-0253
  • Fax:
Mailing address:
  • Phone: 833-664-8244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JULIE DOMINGUEZ
Title or Position: PRESIDENT
Credential: MD
Phone: 833-644-8244