Provider Demographics
NPI:1104208461
Name:DOMINOWSKI, JESSICA DAWN
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:DAWN
Last Name:DOMINOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:DAWN
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:3833 CHIPPEWA CT
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-4305
Mailing Address - Country:US
Mailing Address - Phone:712-301-1889
Mailing Address - Fax:712-224-2775
Practice Address - Street 1:421 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51101-1311
Practice Address - Country:US
Practice Address - Phone:712-224-2774
Practice Address - Fax:712-224-2775
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA007780104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker