Provider Demographics
NPI:1114440237
Name:DOMECUS, JACQUELINE ANN (PTA)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:DOMECUS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:JACKIE
Other - Middle Name:ANN
Other - Last Name:DOMECUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:318 TURNBERRY WAY
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94591-4346
Mailing Address - Country:US
Mailing Address - Phone:707-333-5347
Mailing Address - Fax:
Practice Address - Street 1:3273 CLAREMONT WAY STE 101
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3328
Practice Address - Country:US
Practice Address - Phone:707-603-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2017-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48776225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant