Provider Demographics
NPI:1083003842
Name:DOMINIAK, JARROD (ATC)
Entity type:Individual
Prefix:
First Name:JARROD
Middle Name:
Last Name:DOMINIAK
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10101 S 27TH ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-7209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10101 S 27TH ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-7209
Practice Address - Country:US
Practice Address - Phone:414-520-3886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-16
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1343-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer