Provider Demographics
NPI:1417229899
Name:DOMINGUEZ, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8407 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-3423
Mailing Address - Country:US
Mailing Address - Phone:323-971-1325
Mailing Address - Fax:323-971-1365
Practice Address - Street 1:2101 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-4521
Practice Address - Country:US
Practice Address - Phone:562-218-1868
Practice Address - Fax:562-591-0346
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-01
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-KYBVEP175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist