Healthcare Provider Details

I. General information

NPI: 1346791795
Provider Name (Legal Business Name): JASON DOMINGO MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 RICH ST
BUFFALO NY
14211-3020
US

IV. Provider business mailing address

255 DELAWARE AVE STE 300
BUFFALO NY
14202-2017
US

V. Phone/Fax

Practice location:
  • Phone: 716-895-7715
  • Fax:
Mailing address:
  • Phone: 716-842-0440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: