Provider Demographics
NPI:1295512796
Name:DOMINGUEZ, JONATHAN
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:DOMINGUEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W 21ST ST
Mailing Address - Street 2:
Mailing Address - City:CONCORDIA
Mailing Address - State:KS
Mailing Address - Zip Code:66901-5200
Mailing Address - Country:US
Mailing Address - Phone:785-243-8900
Mailing Address - Fax:
Practice Address - Street 1:210 W 21ST ST
Practice Address - Street 2:
Practice Address - City:CONCORDIA
Practice Address - State:KS
Practice Address - Zip Code:66901-5200
Practice Address - Country:US
Practice Address - Phone:785-243-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-11
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLPC04302101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional