MEDICARE: JESSE DOMINGUEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	156F00000X	Technician/Technologist	67047515A	IN

General Provider Information

NPI Number	:	1245198696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSE DOMINGUEZ

Provider Business Mailing Address
First Line	:	1131 SINCLAIR ST
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46808-2647
Country	:	US
Telephone Number	:	260-710-1290
Fax Number	:

Provider Business Practice Location Address
First Line	:	7970 W JEFFERSON BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-4140
Country	:	US
Telephone Number	:	260-435-6100
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2026
Last Update Date	:	01/14/2026

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Directions to “ JESSE DOMINGUEZ ” Practice Location

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