Provider Demographics
NPI:1558582056
Name:DOMENICO-BROCK, JENNIFER HOLLY (FNP)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:HOLLY
Last Name:DOMENICO-BROCK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3701 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-3611
Mailing Address - Country:US
Mailing Address - Phone:303-360-6276
Mailing Address - Fax:
Practice Address - Street 1:701 24TH ST
Practice Address - Street 2:
Practice Address - City:GOLDEN
Practice Address - State:CO
Practice Address - Zip Code:80401-2379
Practice Address - Country:US
Practice Address - Phone:303-360-6276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.0112072163W00000X
COAT.00008412255A2300X
COAPN.0003864-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer