Healthcare Provider Details

I. General information

NPI: 1821919655
Provider Name (Legal Business Name): JENNIFER DOMINGUEZ UMANA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2026
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1056 W JERICHO TPKE
SMITHTOWN NY
11787-3212
US

IV. Provider business mailing address

39 OWENS ST
BRENTWOOD NY
11717-6617
US

V. Phone/Fax

Practice location:
  • Phone: 631-656-9550
  • Fax:
Mailing address:
  • Phone: 718-845-2621
  • Fax: 718-845-2622

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number131411-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: