Provider Demographics
NPI:1477702850
Name:DOMINIQUE, JEAN C (LMSW)
Entity Type:Individual
Prefix:MR
First Name:JEAN
Middle Name:C
Last Name:DOMINIQUE
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 LENOX RD
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-1016
Mailing Address - Country:US
Mailing Address - Phone:516-377-6249
Mailing Address - Fax:718-221-7240
Practice Address - Street 1:160 LENOX RD
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-1016
Practice Address - Country:US
Practice Address - Phone:516-377-6249
Practice Address - Fax:718-221-7240
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY071318-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical