Provider Demographics
NPI:1275268088
Name:MEJIA DOMINGUEZ, JOSE INES
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:INES
Last Name:MEJIA DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:
Other - Last Name:MEJIA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9890 COUNTY FARM RD STE 3
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3678
Mailing Address - Country:US
Mailing Address - Phone:951-509-2499
Mailing Address - Fax:
Practice Address - Street 1:9890 COUNTY FARM RD STE 2
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503-3678
Practice Address - Country:US
Practice Address - Phone:951-509-2499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health