Provider Demographics
NPI:1750889507
Name:DOMINGUEZ JR, JUAN R JR (MA)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:R
Last Name:DOMINGUEZ JR
Suffix:JR
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7101 W ARCHER AVE STE 402
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-2231
Mailing Address - Country:US
Mailing Address - Phone:773-603-5266
Mailing Address - Fax:
Practice Address - Street 1:7101 W ARCHER AVE STE 402
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638-2231
Practice Address - Country:US
Practice Address - Phone:708-800-5162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health