Provider Demographics
NPI:1235372939
Name:DOMINGO, JESSICA SALIBO
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SALIBO
Last Name:DOMINGO
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 1:1016 LAELAE ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-9482
Mailing Address - Country:US
Mailing Address - Phone:808-244-9819
Mailing Address - Fax:
Practice Address - Street 1:1016 LAELAE ST
Practice Address - Street 2:
Practice Address - City:WAILUKU
Practice Address - State:HI
Practice Address - Zip Code:96793-9482
Practice Address - Country:US
Practice Address - Phone:808-244-9819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIHI020901397376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI59755201Medicaid