Provider Demographics
NPI:1457915514
Name:DOMBOVY, JENNIFER (LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:DOMBOVY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:157 N STARR AVE
Mailing Address - Street 2:
Mailing Address - City:NEW RICHMOND
Mailing Address - State:WI
Mailing Address - Zip Code:54017-1229
Mailing Address - Country:US
Mailing Address - Phone:320-292-9955
Mailing Address - Fax:
Practice Address - Street 1:157 N STARR AVE
Practice Address - Street 2:
Practice Address - City:NEW RICHMOND
Practice Address - State:WI
Practice Address - Zip Code:54017-1229
Practice Address - Country:US
Practice Address - Phone:320-292-9955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI9096-1231041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical