Healthcare Provider Details

I. General information

NPI: 1407445745
Provider Name (Legal Business Name): JESSICA DOMINGUEZ RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/29/2025
Certification Date: 01/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 KALISA WAY STE 211
PARAMUS NJ
07652-3538
US

IV. Provider business mailing address

331 NEWMAN SPRINGS RD STE 220
RED BANK NJ
07701-5792
US

V. Phone/Fax

Practice location:
  • Phone: 800-736-3739
  • Fax: 201-652-6253
Mailing address:
  • Phone: 732-807-0877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86072795
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: