Provider Demographics
NPI:1861644080
Name:DOMINGUEZ, JANESSA (PHD)
Entity Type:Individual
Prefix:
First Name:JANESSA
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6950 W WEDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33331-2946
Mailing Address - Country:US
Mailing Address - Phone:954-715-0679
Mailing Address - Fax:
Practice Address - Street 1:6950 W WEDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33331-2946
Practice Address - Country:US
Practice Address - Phone:954-715-0679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 106H00000X
FL1-11-8594103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist