Provider Demographics
NPI:1518749092
Name:DOMINGUEZ, JESSICA (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 HOPE AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-6707
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1135 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2353
Practice Address - Country:US
Practice Address - Phone:973-928-3388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-18
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY030723363A00000X
NJ25MP00812900363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant