Provider Demographics
NPI:1043553118
Name:DOMINGOS, JAMIE NICOLE
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:NICOLE
Last Name:DOMINGOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 MACARTHUR BLVD
Mailing Address - Street 2:501
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-3274
Mailing Address - Country:US
Mailing Address - Phone:805-423-3582
Mailing Address - Fax:
Practice Address - Street 1:1340 ARNOLD DR STE 225
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:CA
Practice Address - Zip Code:94553-4189
Practice Address - Country:US
Practice Address - Phone:925-655-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
CA108004106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program