Provider Demographics
NPI:1508067299
Name:DOMAN, JACK L JR (LMFT)
Entity Type:Individual
Prefix:MR
First Name:JACK
Middle Name:L
Last Name:DOMAN
Suffix:JR
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:362 RIDGEMONT CT
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-4837
Mailing Address - Country:US
Mailing Address - Phone:805-480-1167
Mailing Address - Fax:
Practice Address - Street 1:550 SAINT CHARLES DR
Practice Address - Street 2:SUITE 101A
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3951
Practice Address - Country:US
Practice Address - Phone:805-480-1167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC38923106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist