Provider Demographics
NPI:1558658807
Name:DOMACHOWSKI, JON M (MA, PLPC)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:M
Last Name:DOMACHOWSKI
Suffix:
Gender:M
Credentials:MA, PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4400
Practice Address - Country:US
Practice Address - Phone:314-516-7231
Practice Address - Fax:314-516-6624
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011020016101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor