MEDICARE: DESTINY JAZZMAN DOMINGO

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	106S00000X	Behavior Technician		CA

General Provider Information

NPI Number	:	1831658178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY JAZZMAN DOMINGO

Provider Business Mailing Address
First Line	:	7226 SEPULVEDA BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91405-2003
Country	:	US
Telephone Number	:	818-235-1414
Fax Number	:

Provider Business Practice Location Address
First Line	:	1320 E SHAW AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93710-7919
Country	:	US
Telephone Number	:	818-235-1414
Fax Number	:

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

Provider Enumeration Date	:	03/17/2019
Last Update Date	:	03/17/2019

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Directions to “ DESTINY JAZZMAN DOMINGO ” Practice Location

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