Provider Demographics
NPI:1669947867
Name:DOMINGUEZ, JORDAN MARCUS
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:MARCUS
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 1:3392 SAN MARDO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-1135
Mailing Address - Country:US
Mailing Address - Phone:925-822-8370
Mailing Address - Fax:
Practice Address - Street 1:1101 S WINCHESTER BLVD STE N260
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3901
Practice Address - Country:US
Practice Address - Phone:408-654-9311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-04
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician