Provider Demographics
NPI:1043942105
Name:DOMINGUEZ, JAENA MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JAENA
Middle Name:MICHELLE
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:OAKWOOD PROFESSIONAL BUILDING
Mailing Address - Street 2:1615 OAKWOOD ST., SUITE D
Mailing Address - City:BEDFORD
Mailing Address - State:VA
Mailing Address - Zip Code:24523-4592
Mailing Address - Country:US
Mailing Address - Phone:540-586-3089
Mailing Address - Fax:
Practice Address - Street 1:1613 OAKWOOD ST
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:VA
Practice Address - Zip Code:24523-1213
Practice Address - Country:US
Practice Address - Phone:843-494-8441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-008657363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant