Provider Demographics
NPI:1457016297
Name:DOMINGO, JENNA MICHELE (LPC)
Entity Type:Individual
Prefix:
First Name:JENNA
Middle Name:MICHELE
Last Name:DOMINGO
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:MICHELE
Other - Last Name:D'AMELIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:312 AMBOY AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:METUCHEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08840-2455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:312 AMBOY AVE STE 2
Practice Address - Street 2:
Practice Address - City:METUCHEN
Practice Address - State:NJ
Practice Address - Zip Code:08840-2455
Practice Address - Country:US
Practice Address - Phone:732-902-2181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-06
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00853000101YP2500X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health