Provider Demographics
NPI:1093437816
Name:DOMINGUEZ, JENNIFER
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DOMINGUEZ
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 1:8724 NW 146TH LN
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33018-8054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8724 NW 146TH LN
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33018-8054
Practice Address - Country:US
Practice Address - Phone:786-537-1406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant