Provider Demographics
NPI:1720048184
Name:DOMINA, JASON MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:DOMINA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68154-3433
Mailing Address - Country:US
Mailing Address - Phone:402-885-0256
Mailing Address - Fax:
Practice Address - Street 1:4235 N 90TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68134-4136
Practice Address - Country:US
Practice Address - Phone:402-934-0045
Practice Address - Fax:402-934-6562
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2400225100000X
IA03847225100000X
AZ7859225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ119081Medicare PIN