Provider Demographics
NPI:1457088700
Name:DEDOMENICO, JESSICA TAYLOR (MS,LAT, ATC)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:TAYLOR
Last Name:DEDOMENICO
Suffix:
Gender:F
Credentials:MS,LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 CR-64
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08724
Mailing Address - Country:US
Mailing Address - Phone:732-800-9000
Mailing Address - Fax:
Practice Address - Street 1:110 CARTAGENA DR
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-7005
Practice Address - Country:US
Practice Address - Phone:609-495-5899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-05
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MT003071002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer