Healthcare Provider Details

I. General information

NPI: 1417454364
Provider Name (Legal Business Name): JACQUELINE DOMPEREH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2018
Last Update Date: 04/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 KING CENTRE DR STE 600
ALEXANDRIA VA
22315-5755
US

IV. Provider business mailing address

5680 KING CENTRE DR STE 600
ALEXANDRIA VA
22315-5755
US

V. Phone/Fax

Practice location:
  • Phone: 703-647-3826
  • Fax: 703-546-0840
Mailing address:
  • Phone: 703-647-3826
  • Fax: 703-546-0840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: